Prenatal Pilates. Gemma Sadler 15 th January 2018 Sydney, Australia

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1 Prenatal Pilates Gemma Sadler 15 th January 2018 Sydney, Australia 1

2 Abstract Pregnancy is such a special time of a women s life and this particular subject lies close to my heart having had two beautiful children of my own practicing Pilates everyday throughout my entire pregnancy. Pregnancy and childbirth has major impacts on a women s body, both internally and externally. During pregnancy every system of the body is effected including; respiratory, cardiac/circulatory, hormonal, and musculoskeletal. Many of these factors could lead to tiredness, swelling, lower back pain, pelvic joint pain, carpal tunnel symptoms, rectus diastasis, postural changes, lower back pain and pelvic floor weakness and pain. There is no doubt that Pilates is one of the best ways to exercise safely during pregnancy and planning exercise modifications throughout the three trimesters are imperative. 2

3 Table of Contents 1. Subject 2. Abstract 3. Table of content 4. Anatomical Description of a few common issues during pregnancy a. Recites Diastasis b. SIJ and Pubic Symphysis Pain c & d Biomechanics of the lumbar spine during pregnancy 5. Pilates guide for the entire three trimesters of pregnancy 6. Case Study 7a &b BASI program 8. Conclusion 9. Bibliography 3

4 Anatomical Description Rectus Diastasis Definition: Diastasis recti is a fairly common condition of pregnancy and postpartum in which the right and left halves of Rectus Abdominis muscle spread apart at the body's mid line fascia, the linea alba. During pregnancy, as your baby grows, the uterus pushes against the abdominal wall. Pregnancy hormones allow the connective tissue to relax and soften. As this pressure increases, the right and left sides of the rectus abdominis (the six pack muscles) begin to widen at the linea alba, which is the connective tissue where your abdominal muscles meet. The muscles don t tear or rupture, but a gap occurs between them. Usually the separation occurs in the third trimester but can also happen after pregnancy, when the abdominal wall is weakened and there isn t a baby inside to support the muscles. During pregnancy, there are a few symptoms of diastasis recti mainly feeling a gap, or even a bulge, on either side of the midline of your belly. There has been studies showing that the condition is more common among who do not exercise during pregnancy. This diagram below shows the difference between a normal abdomen and one that has suffered from Rectus Diastasis. 4

5 SIJ and Pubic Symphysis Pain The Sacro-lliac Joint (SIJ) and Pubic Bone are some of the main structures to feel the systemic effects of pregnancy. As the pregnancy processes especially the third trimester, the pelvic ligaments increase in laxity, making both Pubic Symphysis Joint and SIJ very unstable. Along with the ligaments increase in laxity, the abdominal muscles become less effective and unable to work properly as the baby grows, and the abdominals are usually what helps stabilise the pelvic joins along with the ligaments. Furthermore, carrying towards the third trimester, as the baby descents lower into the pelvis, the pelvis actually needs to expand and separate to accommodate room for the baby s head, as a result in some causing quite a lot of pain in the Pubic Symphysis and SIJ if the pelvis is unstable. The only way to improve on the stability of the SIJ would be to increase the system of force closure. Thus, core stability exercises are recommended for an unstable SIJ to increase the compressive force. Sometimes, a sacro-iliac belt is prescribed to complement the core stability exercises such as Pilates. The sacroiliac joints lie below the dimples in your low back. Each joint is between the Innominate bone (A) and the Sacrum (B). These joints are involved in movements of the low back and hips such as walking, moving between sitting and standing, climbing stairs, etc. The pubic symphysis is the joint (E) at the front of the pelvis between the two innominates (A) at the pubic ramus (D). This joint rotates and compresses, especially during the gait/walking cycle. A: Innominate Bone B: Sacrum C: Acetabulum ( cup of the hip joint) D: Pubic Ramus E: Pubic Symphysis or joint F: Ischial Tuberosity or sit bone 5

6 Biomechanics of the Lumbar Spine during Pregnancy The vertebral bodies in the caudal lumbar spine are larger than those in the cervical and thoracic spine, which allows them to accommodate the added weight and stress when a person is in an upright posture. The functional units of the vertebral bodies can be divided into anterior and posterior portions. The anterior portion, comprising the vertebral bodies and the intervertebral discs between them, provides support and weight-bearing strength as well as shock absorption. The posterior portion of the functional unit, which is the nonweight-bearing portion, includes the vertebral column that houses and protects the spinal cord. It also contains the facet joints, which are diarthrodial joints. Like all other diarthrodial joints in the body, they have a joint cavity between the articulating bones and are freely moveable. Their role is to direct movements of the functional unit as a whole in flexion, extension, and lateral bending. The load and shearing forces acting on the lumbar spine are greater than those on the cervical and thoracic spine because of the larger amount of body mass the lumbar spine must support as well as the lordotic curve in the lumbar spine. These factors make the lumbar spine more vulnerable to degenerative changes and disc herniations. During pregnancy, a woman develops postural changes that are necessary for her to maintain balance in the upright position. The average weight gain with a single fetus is 10 to 12kg. The increasing weight is distributed primarily in the woman's abdominal girth. After 12 weeks of pregnancy, the uterus can no longer be contained within the pelvis and the mass moves superiorly and anteriorly. As the abdominal muscles are stretched and tone is diminished, they lose their ability to contribute effectively to the maintenance of neutral posture. With these biomechanical changes, it was thought that lumbar lordosis increased; however, studies have shown that the lordosis remains the same or increases only slightly. [7] Instead, what seems to happen is that the entire spine shifts to a more posterior position, and the centre of gravity as a whole tends to move in a posterior and caudal direction. As pregnancy continues, production of the hormone relaxin increases ten-fold, reaching its peak between weeks 38 and 42 weeks gestation. Relaxin creates joint laxity, which is necessary to allow the pelvis to accommodate the enlarging uterus. Joint laxity is more pronounced in multiparous women than it is in nulliparous women. In the lumbar spine, joint laxity is most notable in the anterior and posterior longitudinal ligaments. This weakens the ability of static supports in the lumbar spine to withstand the shearing forces. As a result, there may be an increase in discogenic symptoms and/or pain coming from the facet joints. In the pelvis, joint laxity is most prominent in the symphysis pubis and the sacroiliac joints. The symphysis pubis continues to widen throughout pregnancy from its normal width of 0.5mm to a maximum of approximately 12mm. With this widening, there is the risk of vertical displacement of the pubis and the possibility of rotatory stress on the sacroiliac joints. The sacroiliac joints themselves tend to be extremely stable joints; they have anterior and posterior tight ligamentous structures as well as a curved and sigmoid articular surface that limits movement. Movement in the sacroiliac joint can be dramatically increased throughout pregnancy, however. This movement can stretch pain-sensitive structures, causing sacroiliac pain. 6

7 Education is crucial. Even before becoming pregnant, a woman who is contemplating a pregnancy must be evaluated. A careful history should be obtained as to prior low-back problems. If she gives a positive history, then questions should address whether these 4c Problems have been completely worked up and treated in the past. She should also be educated as to the increased risk of developing recurrent symptoms during her pregnancy. Pre-pregnancy, physically fit women who engage in 45 minutes or more of physical activity per week are less likely to develop low-back pain during pregnancy. Pre-pregnancy fitness, however, does not seem to reduce the risk of sacroiliac pain. There are some general principles that benefit all pregnant women. These include proper posture, a regular exercise program, and awareness of the low-back biomechanics that are most ergonomic to alleviate any mechanical stress on the lower back. Pregnant women should understand that with weight gain and hormonal changes, the distribution of weight will be displaced and exert more stress on the lower back and pelvis, and at the same time, the ligaments and joints will become more lax. They should also be aware of the importance of proper posture in preventing unnecessary mechanical stress on the lower back. Further, pregnant women should be taught how to maintain a neutral spine posture--that is, how to avoid excessive lumbar lordosis and excessive reversal of lumbar lordosis--during all activities. The Diagram below shows the spinal changes during pregnancy. 7

8 4d 8

9 Pilate s modification, a guide for the three trimesters of pregnancy First Trimester (1-12 Weeks) The mother-to-be may be experiencing morning sickness or feeing very tired. This initial stage of pregnancy is where there is most risk of miscarriage. Avoid temperature increasing too high Decrease cardio output by 15% Reduces sit up exercises Second Trimester (13-26Weeks) The baby continues to grow and will start showing at this time. Avoid strengthening the Rectus Abdominus Avoid inner thigh work Avoid prone positions Supine position for a small amount of time. Third Trimester (27 weeks to Birth) During the third trimester, the mother s posture changes dramatically due to the baby s growth, this is where a lordosis- kyphosis posture becomes more evident. Avoid all abdominal exercises Decrease exercise intensely Avoid inner thigh work Avoid prone position Avoid supine position 5 9

10 Case Study Emma is fit and strong individual age 32 years and is currently carrying her first child at 14 weeks gestation. Emma has been practicing Pilates 3-4 group class sessions per week for the past 2 years and is quite strong especially around her core. Emma is very fit and has no preexisting injuries As Emma has been participating in regular group sessions, therefore I ve highlighted the fact that now is the critical time to focus on specific prenatal exercises which will help her body cope with the upcoming months of pregnancy, to maintain strong core muscles, maintain muscle tone and facilitate good posture and spinal alignment and minimize back pain in a safe and effective routine. Emma is extremely hopeful to continue Pilates with me until the day she gives birth. The following program has been designed for Emma using variety of different Pilates equipment to keep Emma feeling challenges and stimulated thought the hour long session. Due to Emma entering her second trimester he Warm Up has been slightly modified. 6 10

11 Emma s Program Assessment Roll down 1. Warm up (Mat) a. Pelvic Curl b. Spin Twist Supine c. Chest lift d. Chest lift with rotation e. Leg circles 2. Foot Work (Wunda Chair) a. Parallel Heels b. Parrallel Toes c. V Position Toes d. Open V Heels e. Open V Toes f. Calf Raises g. Single Leg Heels h. Single Leg Toes 3. Ab Work ( Cadillac) a. Mini Roll Up b. Mini Roll Up with Obliques 4. Hip Work (Cadillac) a. Frog b. Circles Down c. Circles Up d. Walking e. Bicycles 5. Spinal Articulation (Reformer) a. Bottom Lift b. Bottom Lift with extensions 7a 11

12 6. Stretches (Reformer) a. Standing Lunge 7. Full Body Integration (Cadillac) a. Sitting Forward b. Side Reach 8. Arm work (Cadillac) Arms Standing Series a. Chest Expansion b. Hug-a-Tree c. Circles Up d. Circles Down e. Punches f. Biceps 9. Full Body Integration 2 (omitted) 10. Leg Work (Mat) Gluteal Kneeling Series a. Hip Extension b. Bent Knee c. Hip Abduction d. Bent Knee e. High Extension f. Straight Leg 11. Lateral Flexion/Rotation (Wunda Chair) a. Side over 12. Back Extension (Mat) Cat Stretch 13. Final Assessment Roll Down 7b 12

13 Conclusion I truly believe that it is extremely important to carefully consider a tailored Pilates exercise program while you are pregnant. Not only does it make you feel good and improve your post-natal recovery, there is an increasing amount of research that shows a considerable positive effect on both yours and your baby s long-term health. In a nut shell here is a few key points on the benefits from practicing Pilates during pregnancy Strengthen your stomach and gluteal muscles Reduces back pain Strengthen your pelvic floor Control your breathing Improve balance Maintain healthy weight Speed up postal recovery 8 13

14 Bibliography 1. BASI - Isacowitz Rael Study Guide, Comprehensive Course, Costa Mesa, USA. 2. Studio Pilates International Pilates for Pregnancy, QLD, Australia 3. Fixing Back pain During Pregnancy, Rick Oldman, Boone Publishing 4. Diastasis Recti Abdominis, Physiotherapy & Functional Wellness, Katrina M Gallus 9 14