Abdominal muscle bracing

Transcription

1 Abdominal muscle bracing and back care in pregnancy p r o m o t i n g Abdominal muscle bracing and back care in pregnancy Presenter s manual b l a d d e r a n d b o w e l h e a lt h

2 Notes for the presenter This presentation is included as additional information to compliment the presentation Pelvic floor muscles their importance during pregnancy and childbirth. Recent studies show that there are links between back pain and incontinence, and suggest that the links are because of the relationship between the back, abdominal and pelvic floor muscles and how well each area is working. Research suggests that the control and coordination of the abdominal muscles and the pelvic floor muscles both have an impact upon the development of incontinence. As with pelvic floor exercises, it is equally important to consider correctly and safely exercising the abdominal muscles during and after pregnancy. As an ante natal educator, options for including this presentation into your classes include: 1. Introducing the section on the topic of changes to a woman s body early in the series of antenatal classes starting with back care tips and abdominal muscle bracing exercises and then moving into pelvic floor exercises. These provide women and their supporters with helpful hints. 2. When introducing pelvic floor exercises to ante natal classes, by expanding your existing level of discussion using the information in this presentation. Pelvic floor discussion is often timely following the discussions on second stage of labour. This is often when women think about the effects of the birth on their muscles. An earlier introduction to pelvic floor muscle exercises in the series, and the commencing of doing the exercises (or improvement of their technique) is also of benefit. 3. Using ideas from this presentation in your ante natal class (eg. when practicing positions in labour for first stage). Include practicing of pregnancy abdominal bracing when talking about optimal foetal positioning (see also the fact sheet on that topic). It is also useful to discuss the importance of good posture. Back care tips can be discussed when talking about post natal choices of equipment, and looking after yourself during pregnancy and after the birth. When discussing the benefits of rest and relaxation, positions of comfort and the use of pillows, cushions and back supports can be included. These resources give opportunities to add variety to your antenatal classes, and allow your knowledge to flow into the homes and the lives of the women and their supporters who attend your classes. This resource has been developed by the Continence Foundation of Australia in collaboration with The Pregnancy Centre. Continence Foundation of Australia September 2008 Disclaimer This resource is intended as an information guide about pelvic floor muscles and is not intended as a treatment program for specific conditions. No responsibility is taken for exercises not done appropriately or if they are ineffectual. The help of an appropriate health professional should be sought if symptoms are experienced.

3 Posture changes during pregnancy Due to relaxin hormone Due to growing baby Relaxing of pelvic joints and ligaments Extra care needed of spine and pelvis Slide 1 Posture changes during pregnancy Outline the physical changes affecting the spine. Use model of spine to demonstrate if one is available, otherwise demonstrate on self. Advise about strategies to deal with these changes (eg. orientate to normal posture using spine with three curve): inwards curve in the neck (cervical lordosis) outwards curve in upper back (thoracic kyphosis) inwards curve in the lower back (lumbar lordosis) Demonstrate the postural changes that occur with pregnancy: increased lumbar lordosis due to the increased size and weight of the uterus as the baby grows increased thoracic kyphosis (also due to increased breast size) Explain relaxin hormone effects causing ligamentous laxity. Demonstrate stretch to ligaments that can occur with bending or slouching by bending spine (if available) to show effect on spinous processes moving further apart. A finger stretch exercise can be used to demonstrate the effect of strain on ligaments. Get participants to stretch one finger back and hold for 10 seconds and then release. The stiffness and discomfort felt in the finger after a short stretch can alert participants to the effects of poor posture and bending over for sustained periods. Show position of the symphysis pubis and sacroiliac joints and explain about loosening effects due to preparation for opening during labour to make it easier for the baby to move through the pelvis.

4 Back care Posture stand tall, sit with back supported Take care when getting out of a chair Moving from lying to sitting Sleeping position tips: Use pillows between legs Keep back in line Help reduce strain on hips and back Importance of rest Slide 2 Back care Posture tips Stand tall push top of head to ceiling, lengthening spine (eg. like having a string pulling you up from top of head). Sitting posture sit with back supported and consider suitable feeding positions for after the birth. Taking care when getting out of a chair To get out of a low or lounge chair, it is important to wiggle forwards and then use the legs and arms to assist getting up, rather than straining from the abdominal muscles. Moving from lying to sitting To move from lying to sitting, avoid jacknifing. Bend knees, roll on to side, and use hands to push self up. This helps to reduce the strain on the abdominal muscles and back during pregnancy and after the birth. Sleeping position tips Suggestions for sleeping positions using pillows. Show the use of a pillow between the lower leg as well as the thigh. Many women use one pillow, but the lower leg can still drop forwards and put pressure on the spine, hips or pelvis. An extra pillow can help increase comfort and reduce the strain on the spine, hips and pelvis. Importance of rest Explanation of physical changes causing tiredness increased blood volume, weight gain, extra demands on the body. Encourage appropriate rest and the use of comfortable positions such as the supported side lying position above, rather than slouching in a lounge chair.

5 Postnatal back care tips Outline postnatal back care tips/expand if time available: Post natal back care is important as you often do more lifting, bending and carrying when you have a baby. Consider pram and change table height when you are buying equipment. Use the wrist crease as a way of checking the height of equipment as this will allow a slight comfortable bend at the elbows, and allow the back to be kept straight. Consider where you are going to bath your baby. Consider sitting posture and use of lumbar supports and suitable chairs for when feeding your baby. More back care tips Massage relieves back ache relieves neck and shoulder tension a variety of techniques available Hot packs can also help Courtesy of Bumps Pilates, Melbourne Slide 3 Fact sheet Caring for your back during and after pregnancy Hand out the fact sheet Caring for your back during and after pregnancy. Back pain is very common. 47% of women during pregnancy and 80% of Australians at some stage of their lives have back pain. Just because it is common, it does not mean that it is normal to have back pain. Recent studies show that there are links between back pain and incontinence, and suggest that the links are because of the relationship between the back, abdominal and pelvic floor muscles and how well each area is working. There are different kinds of back pain that can be experienced. These include: Aches Often the muscles get tired or achy, particularly towards the end of the day. This kind of pain is often due to posture and the activities which you are doing during the day. If your abdominal muscles are weakened, e.g. during or after pregnancy, there will be more strain placed on your back throughout the day. Refer to the fact sheet Pregnancy and post natal abdominal muscle bracing to learn how to strengthen your muscles safely during and after pregnancy. You may also be bending over, using your back rather than bending your knees and hips, using your stronger leg muscles. Often paying attention to these things your posture, bending your knees and lifting correctly, and bracing your abdominal can help reduce this type of pain. Sharp, pinching or catching pain You should not continue to put up with any pain of this nature. Rather than applying general advice (although the above tips may still be helpful) in this situation, you should seek professional advice regarding what is causing the pain and specific treatment options available. Numbness or tingling or pain moving down into your leg This indicates irritation to or pressure on the nerves from your back. You should quickly seek advice from your doctor, physiotherapist or other health professional if you develop this problem. Do not ignore it and hope that it will just go away. Please note: This information is not a substitute for seeking professional advice if you have or develop a back problem. What can you do if you have a backache? Use a hot pack (Do not use if you have recently hurt your back or had an injury, seek professional advice.) The heat from a hot pack can help to improve the blood flow to your aching muscles and help them to relax. There are different forms of hot packs which you can use. It is important to make sure that you don t have it too hot. It should just feel comfortably warm while you are using it against the area that is aching. You can use heat for up to 5 20 minutes at a time, even as often as every 3 4 hours. Check your posture If you stand and let your tummy sag there will be more strain against your back. Stand tall and think strong and firm in your waist area as you hold your baby or stand in one position for any period of time. Use your muscles to hold you up and they will become stronger and a greater support for your back. Your shoulders should be pulled back and slightly down, your chin tucked in and your knees gently fixed, not pushed back. Bend, bend, brace Bend your knees, bend your hips, and brace your abdominals to protect your back as you reach down to drawers, into cupboards, pick things up from a low height or lift heavy objects. Make a habit of doing this throughout the day and it will reduce the strain on your back. As an added bonus you will also develop stronger and more toned thighs! Reproduced with kind permission from The Pregnancy Centre For further information visit Contact the National Continence Helpline on or Continence Foundation of Australia The Pregnancy Centre 2008 page of 3 Related fact sheet: Caring for your back during and after pregnancy

6 Pregnancy and abdominal bracing Abdominals relaxed Abdominals braced Courtesy of The Pregnancy Centre Slide 4 Pregnancy and abdominal bracing Teach abdominal muscle bracing or actively carrying the baby. Explain with diagrams or using hands to demonstrate the transversus abdominus and internal obliques position. Explain their supportive function and the importance of maintaining abdominal muscle tone to support the baby during pregnancy and reduce the strain on the pelvis and lumbar spine. Sell the exercise as one that can be done throughout pregnancy. It won t hurt the baby as long as they don t hold their breath during the exercise. Explain the postnatal benefits of the exercise: This is also the exercise which we get you to do soon after you have had your baby to help start to get the muscles back to normal again. Even women who have a caesarian can start these exercises within about 4 5 days. It is not too late to start if you haven t been doing the exercise, and if you start your muscles will be more toned and it will be easier to do the exercise after the birth.

7 Fact sheet Pregnancy and post natal abdominal muscle bracing Hand out the fact sheet Pregnancy and post natal abdominal muscle bracing. Learning to brace or actively contract (ie. gently and accurately tightening) your stomach muscles is important during pregnancy. Bracing will help you keep your muscles toned so they can support your baby and reduce the strain on your back. Strengthening your muscles during pregnancy will make it easier for you to regain your muscle strength and tone after your baby is born. While you are pregnant it is not suitable for you to continue with traditional abdominal exercises, such as sit-ups and curl ups. Many of these exercises mainly work the outer abdominal muscles. Bracing involves contracting your deeper abdominal muscles by gently drawing in the abdominal muscles below your belly button, in towards your spine and up slightly, holding this position for as long as you comfortably can. Many women do not brace correctly, so it s a good idea to check your technique against the following tips. You should not try too hard. If you need to hold your breath then stop. You should feel the lower half of your abdominal muscles mainly work, below the belly button You should not feel that you are sucking the muscles in up under your ribcage, otherwise you are mainly working your upper abdominal muscles. You should feel no pressure downwards on your pelvic floor muscles. You may feel your pelvic floor muscles drawing up slightly and this is fine. Some women find it easier to start by drawing in the pelvic floor muscles first and then their lower abdominal muscles. You should feel no pain or discomfort while doing this. If you are still unsure get your technique checked before doing this as an exercise! As your baby grows your stomach muscles need to hold and support extra weight. The lower abdominal muscles especially need more attention as your baby begins to show. To focus more on the lower muscles, place your hand on your abdomen, below your belly-button. Gently pull your stomach muscles away from your hand. If this stops or changes your breathing, you are trying too hard. Stop and start again more gently so you can hold your muscles in while you keep breathing. Positions for learning the exercises include sitting, standing, lying on your side and being on hands and knees. Later in pregnancy many women find that the hands and knees position allows them to feel the muscles working more easily. Once the technique of bracing is learned, these exercises can be done easily in any position and during daily activities. This means you can do it many times a day without setting time aside to exercise. Once you are able to brace or actively contract the muscles for 3 4 seconds aim for 3 4 repeats. Increase to 5 second holds, repeated 5 times, then build up to 0 seconds, repeated 0 times. Once you have built up to this level, you can increase your hold time bracing for as long as comfortable during daily activities such as standing in a queue, doing the dishes, getting up from a chair or lounge, rolling over in bed, walking, pushing a shopping trolley and lifting. Postnatal bracing Start with drawing the muscles in as soon as you are comfortable, within the first few days after the birth. Ensure that you focus on the lower half of your abdominal muscles as outlined for pregnancy abdominal bracing. Some women find this is easy to do, and are able to draw up their pelvic floor muscles up at the same time. Others find that the really need to stop and concentrate on abdominal bracing and pelvic floor muscle exercises separately. Use the method that works for you best, and seek the advice of the physiotherapist who visits you on the maternity ward, or your midwife to check your Reproduced with kind permission from The Pregnancy Centre For further information visit Contact the National Continence Helpline on or Continence Foundation of Australia The Pregnancy Centre 2008 page of 2 Related fact sheet: Pregnancy and post natal abdominal muscle bracing Learning pregnancy abdominal bracing Don t try too hard Breathe normally No pressure downwards on pelvic floor muscles No sucking up under the ribcage No pain or discomfort If unsure, ask! Courtesy of Bumps Pilates, Melbourne Slide 5 Learning pregnancy abdominal bracing Bracing involves contracting your deeper abdominal muscles by gently drawing in the abdominal muscles below your belly button in towards your spine and up slightly, holding this position for as long as you comfortably can. Many women do not brace correctly, so it s a good idea to check your technique against the following tips. You should not try too hard. If you need to hold your breath then stop. You should feel the lower half of your abdominal muscles mainly work, below the belly button. You should not feel that you are sucking the muscles in up under your ribcage, otherwise you are mainly working your upper abdominal muscles.

8 You should feel no pressure downwards on your pelvic floor muscles. You may feel your pelvic floor muscles drawing up and this is fine. Some women find it easier to start by drawing in the pelvic floor muscles first and then their lower abdominal muscles. You should feel no pain or discomfort while doing this. If you are still unsure get your technique checked before doing this as an exercise! Refining the technique To refine the technique to improve the focus on the lower part of the abdominal muscles repeat again using the following instructions: As your baby grows your stomach muscles need to hold and support extra weight. The lower abdominal muscles especially need more attention as your baby begins to show. To focus more on the lower muscles, place your hand on your abdomen, below your belly-button. Gently pull your stomach muscles away from your hand. If this stops or changes your breathing, you are trying too hard. Stop and start again more gently so you can hold your muscles in while you keep breathing. Learning pregnancy abdominal bracing Learning to brace correctly takes practice and concentration Correct technique is BEST! Once learned, hold for 3 4 seconds and repeat 3 4 times Increase to 5 second holds, repeated 5 times then build up to 10 seconds, repeated 10 times Slide 6

9 Abdominal muscle bracing Once learned, 'bracing' can be: continued throughout pregnancy done while walking done during daily activities started soon after the birth gently progressed as it gets easier Courtesy of The Pregnancy Centre Slide 7 Abdominal muscle bracing Positions for learning the exercises include sitting, standing, lying on your side and being on hands and knees. Later in pregnancy many women find that the hands and knees position allows them to feel the muscles working more easily. Once the technique of bracing is learned, these exercises can be done easily in any position and during daily activities. This means you can do it many times a day without setting time aside to exercise. Once you are able to brace or actively contract the muscles for 3 4 seconds aim for 3 4 repeats. Increase to 5 second holds, repeated 5 times, then build up to 10 seconds, repeated 10 times. Once you have built up to this level, you can increase your hold time bracing for as long as comfortable during daily activities such as standing in a queue, doing the dishes, getting up from a chair or lounge, rolling over in bed and walking. Brace more strongly to support your back for any activities which cause any discomfort or pulling in your lower abdomen or back such as pushing shopping trolleys around the corner or lifting. Repeated practice within a class setting allows refinement of the technique with each go, and a building of confidence that women can do this exercise easily. There are many opportunities in ante natal education to include ongoing practice of this exercise and pelvic floor muscle exercises once learned. Partners or support people should also be encouraged to do this exercise as it can help with back support for anyone. The instructions pull your belly button in towards your spine can be used for them. Repeat and get women and partners to talk to each other to check that they are not holding their breath. Relax and repeat, trying to breathe normally once you have pulled your muscles in. Emphasise that if you can breathe normally this is a safe exercise to do all the way through pregnancy (eg. It can be done right up until the day you have you re your baby, providing there are no precautions given to you by your doctor or midwife).

10 Stand and do the exercise again, and check again that they can talk to their partners. Then encourage to brace and hold the muscles in while they walk around the room. Advise that it may take a few weeks before they can do the exercise without holding their breath, and to progress to doing other things at the same time (eg. walking or while standing). Remind them that it takes months for the muscles to be stretched during pregnancy, so the muscles don t just return back to normal. This exercise, plus some other postnatal exercises can help to get the muscles pulled back in to normal. Abdominal muscle bracing Abdominal bracing can be progressed under close supervision to ensure correct technique Courtesy of Bumps Pilates, Melbourne Slide 8 10

11 Round ligament pain Abdominal bracing helps Slide 9 Round ligament pain Ask if anyone has had a sharp catchy pain, pointing to the round ligaments. Usually some women in the class will have experienced this. Explain that this is usually the ligaments which hold the uterus which are being stretched. With the weight of the baby in the uterus, sometimes when you move, the uterus moves and pulls on the ligaments, which can be felt as pain. This often happens with sudden changes of direction, getting out of bed or off the floor, out of a chair or going up or down stairs. Reassure that as long as this pain comes and then goes away, and does not last, it is usually just round ligament pain. Mention that if any pain does not go, it is important to check with your doctor or a midwife. Explain that abdominal bracing can help in two ways: By bracing regularly, your abdominal tone will be improved and will support the uterus better so there will be less extra stretch on the ligaments during daily activities. By bracing during activities that cause pain, this can support the uterus and reduce the strain on the ligaments. 11

12 Where to get professional help National Continence Helpline (freecall) Australian Physiotherapy Association (03) or visit Slide 10 Where to get professional help National Continence Helpline (freecall) The National Continence Helpline (freecall) can provide information about local continence services, and the name of your nearest continence and women s health physiotherapist, or continence nurse advisor. The Helpline is staffed by a team of continence nurse advisors who offer free information, advice and support and can provide you with a wide range of information resources. The Helpline can also provide you with general information and advice about issues relating to bladder and bowel health. As a health professional presenting this talk, you may be able to provide your own business cards or the business cards or contact numbers of local continence and women s health or pelvic floor physiotherapists or continence nurse advisors. Australian Physiotherapy Association If you are unsure about local physiotherapy services contact the Australian Physiotherapy Association on (03) to find your nearest continence and women s health or pelvic floor physiotherapist. You can also visit and click on Find a Physio or look in the Yellow Pages. 12