Strengthening for the Post- Natal Client

Transcription

1 Strengthening for the PostNatal Client Melissa Macchione June 2016 Beach Pilates Toronto, ON

2 Introduction This paper describes the potential concerns to a postpartum client. Post Natal exercise can begin approximately four to six weeks after a normal vaginal birth or after bleeding has ceased. For delivery complications or Csections, this time frame may be extended. In any case, clearance from a physician is recommended. Some common postpregnancy concerns include: Diastasis Recti Abdominis, Incontinence, Postural Misalignments and CSection problems all of which will be discussed further. My client is 30 years old and had her first baby though a normal vaginal birth 8 weeks ago. Her delivery had no complications and got the approval of her physician to start exercising as soon as it felt right for her. She has some common concerns to be aware of when designing an exercise program and they include: postural misalignments, incontinence, breast tenderness and some abdominal separation, Diastasis Recti Abdominis. To improve her overall postpregnancy body a conditioning program, using the BASI Block System, has been created based on her postural weakness and muscular dysfunctions. Melissa Macchione Student Paper 1

3 Table of Contents Introduction 1 Common PostPregnancy Posture 2 PostNatal Conditions 3 8 Overview Post Natal Physiology Weakened Muscles Diastasis Recti Abdominis Pelvic Floor Incontinence Postural Issues Csection Issues Case Study 9 Conditioning Program for the PostNatal Client Conclusion 13 Bibliography 14

4 Common PostPregnancy Posture Some postural misalignments may remain as a result of pregnancy and the postures that are maintained during the care of an infant. Increased lordosis with tight lower back extensors and tight hip flexors and upper thoracic kyphosis is a very common postpartum posture. Melissa Macchione Student Paper 2

5 The female body undergoes drastic changes during pregnancy as hormones relax the ligamentous structures of the pelvis, the cervix widens and most noticeably our stomachs grow and our tissues stretch to accommodate the child growing inside of us. As adaptable as our bodies can be these changes during pregnancy can continue to impact us long after childbirth. Postnatal exercise can begin approximately four to six weeks after a normal vaginal birth. This time frame may be extended if there were complications during birth or a Csection was performed. In any instance, a physician s approval is required before exercise can begin. There are many potential concerns to a post- partum client that should be taken into consideration. These include: incontinence, diastasis recti, breast tenderness, carpal tunnel syndrome, joint laxity, Csection problems, residual postural issues, fatigue and postpartum depression. Returning to an exercise program which focuses on the inner core unit (the diaphragm, the multifidus, the transverse abdominus and the muscles of the pelvic floor) is crucial for regaining strength of the abdominal wall and stability of the pelvic girdle, low back and thorax. After pregnancy a woman s physiology changes. The abdominal muscles have been stretched and weakened, joints are loose and unstable. Pilates offers a full- body, safe workout to address all of these needs and more. Melissa Macchione Student Paper 3

6 Post Natal Physiology Weakened Muscles Diastasis Recti Abdominis Pelvic Floor Incontinence Postural Issues Csection Issues Weakened Muscles The Core: Diaphragm, Pelvic Floor, Multifidus and Transversus abdominis, need to work synergistically as a team. Optimal function of the core unit is to support, stabilize the spine and pelvis. Retrain the core identify and coactivate the four muscles of the core rather than train the core. Resetting the foundation for proper alignment, breathing and coordination Reestablish the mindbodycore connection Relearn the strategies the body needs to stabilize and support itself Melissa Macchione Student Paper 4

7 Diastasis Recti Abdominis Diastasis rectus abdominis is the splitting of the rectus abdominis (separation of the two recti muscles) with an unnatural distance between left and right muscles. The most healing occurs during the first 8 weeks postnatal, however the rectus abdominis may remain abnormally widened after this period. Without proper support of the rectus abdominis the tummy may sag or dome. Considerations when working with a client who has DRA: Contraindicated movements would be flexion, extension and loaded rotation. It is best to work in a neutral position, focusing on TA engagement. Regain strength and support of the torso and lumbopelvic region. Melissa Macchione Student Paper 5

8 Focus on drawing both sides of the abdominals together with the external obliques. Overuse of the internal obliques may cause the abdominals to spread. DRA can be felt as low back pain, pelvic pain, incontinence, poor muscle tone, pelvic organ prolapse and development of nonoptimal strategies for core stabilization. In early postpartum, separation should minimize within the first 8 weeks (during spontaneous healing). During this period, all fours position should be avoided. Pelvic Floor Pelvic floor is a collection of muscles, tendons, ligaments and tissue that are interwoven and connect to the pubic bone in the front, to the tailbone in the back and to the sits bones the shape looks like a hammock. Function of the Pelvic Floor Stabilize spine and pelvis Support internal organs Sphincter control (continence) Sexual role Sumppump action (with diaphragm) Melissa Macchione Student Paper 6

9 Incontinence A woman may reduce her risk of incontinence by strengthening the pelvic floor. During pregnancy, it s the weight of the baby on the bladder that compromises the pelvic floor. Kegal exercises are very effective to help remedy or improve the issue. Pilates exercises emphasize the importance of the pelvic floor and encourage engagement of the pelvic floor musculature. Considerations when working with a client who experiences incontinence: Pelvic Floor muscles have become stretched and weakened during pregnancy and delivery therefore abdominal muscle engagement may be challenging. Leakage may occur during strenuous movements Client may not mention it because of embarrassment Focus on retraining pelvic floor muscles Even clients who have had a Csection will need to retrain the pelvic floor Postural Issues Due to the weight gain and increased size of the womb during pregnancy and the increased size of the breasts, a woman s center of gravity shifts. The lumbar curve of the spine increases, which in turn tilts the pelvis anteriorly creating weakened abdominals, tight low back extensors and tight hip flexors. Thoracic Kyphosis Melissa Macchione Student Paper 7

10 develops, which is an increase in the thoracic curve of the spine, bringing the shoulders forward creating a weak thoracic spine and tight pectorals. These changes will most typically result in increased tension in the muscles and joints causing pain and discomfort. These postural misalignments and others may be developed during pregnancy (or even prior to pregnancy) but some are maintained during the care of the baby. For example: nursing the baby and changing diapers encourages a thoracic kyphosis. As the baby gets bigger, mom may hold her child on one hip, which would bring further misalignment to the pelvic complex. Csection Issues A doctor s approval is required in the case of a Csection and exercise may not be able to be resumed until 8 weeks or more after surgery. Clients who have had a C- section may be afraid of exercising for the fear of affecting the incision. Pelvic floor retraining is still necessary even though there was not a vaginal delivery. Melissa Macchione Student Paper 8

11 Case Study CLIENT: Female, 31 yearsold, postpartum 8 weeks CONSIDERATIONS: Diastasis Recti Abdominis minimal separation approx.1 finger gap Lumbar Hyperlordosis tight lower back extensors causing lower back discomfort, tight hip flexors and hamstrings, weak glutes, slight hyper- extension in knees Thoracic Kyphosis tight pectorals and upper back extensors, head pulled slightly forward causing neck discomfort Incontinence leakage occurs during strenuous movements such as lifting heavy objects, running and jumping. Breast feeding breast tenderness, laying prone is uncomfortable Some Pilates experience prior to pregnancy. OBJECTIVES: 1. Regain Alignment Pilates not only lengthens and strengthens abdominal muscles, it also focuses on alignment of the spine relative to the pelvis. Teaching my client to identify and understand the difference between a neutral pelvic position, an anterior pelvic tilt and a posterior pelvic tilt, will help her properly train the core muscles and in turn restabilize the pelvis. 2. Stabilize the Pelvic Floor Focus on retraining pelvic floor muscles through proper PF muscle engagement, abdominal engagement, cueing and visualization. 3. Muscles to lengthen hip flexors, spinal extensors, pectorals, hamstrings 4. Muscles to strengthen abdominals, pelvic floor, spinal extensors, glutes

12 Strengthening for the PostNatal Client: The Workout BLOCK & APPARATUS EXERCISE NOTES Roll Down Bringing awareness to the breath and body. An opportunity for the Instructor to notice the client s postural alignment and ability to move her spine sequentially. WARMUP (MAT) Pelvic Curl Supine Spine Twist Leg Lifts/Changes (small ROM) Leg Circles (with exercise band for support) Additional Exercises: Breathing* Pelvic Tilts* Protraction/Retraction* Arm Circles* Hugs* Supine Spine Twist Modification for tabletop: legs parallel, knees bent resting on a stability ball or legs parallel, knees bent with feet on mat FOOTWORK (REFORMER) ABDOMINAL WORK (REFORMER and Parallel Heels Parallel Toes V Position Toes Open V Heels Open V Toes Calf Raises Prances Prehensile Single Leg Heel Single Leg Toes Short Box Series (Round Back, Flat Back, Tilt, Twist) Cues: Pelvic Floor lifts when you exhale and push the carriage out. Pelvic Floor relaxes as you inhale and carriage comes in.

13 WUNDA CHAIR) Standing Pike Standing Pike Reverse HIP WORK Supine Leg Series (REFORMER) SPINAL Bottom Lift ARTICULATION (REFORMER) STRETCHES Standing Lunge (REFORMER and STEP Shoulder Stretch Lying Side BARREL) FULL BODY INTERGRATION (CADILLAC) ARM WORK (REFORMER) Thigh Stretch with Roll up Bar Kneeling Cat Stretch Arms Sitting Series Modification for tight hip flexors, hamstrings and low back: sit up on platform extender LATERAL FLEXION/ROTATION (MAT and STEP BARREL) BACK EXTENSION (MAT and WUNDA CHAIR) Spine Twist Side Lift Cat Stretch Swan Basic Modification for tight hip flexors, hamstrings and low back: sit up on cushion Melissa Macchione Student Paper 11

14 * Breathing Lying Supine pelvis and spine neutral, legs parallel, knees bent, arms by sides Inhale: stay in neutral and expand the sides and back of the rib cage Exhale: engage abdominals Repeat x5 * Pelvic Tilts emphasize the Pelvic Floor muscles contracting on exhale and relaxing on the inhale. Lying Supine pelvis and spine neutral, legs parallel, knees bent, arms by sides Inhale: prepare Exhale: engage abdominals and draw tailbone between legs (posterior tilt) Inhale: segmentally lengthen back to neutral Repeat x5 * Protraction & Retraction Lying Supine pelvis and spine neutral, legs parallel, knees bent, arms perpendicular Inhale: retract scapulae Exhale: protract scapulae Repeat x5 * Arm Circles Lying Supine pelvis and spine neutral, legs parallel, knees bent, arms by sides Inhale: lift arms to perpendicular (or past ears if it is available in the shoulder and if client can maintain rib cage connection),open them out to a T position Exhale: adduct arms, rotate so palms face body, return to starting position Repeat x5 reverse * Hugs Lying Supine pelvis and spine neutral, legs parallel, knees bent, arms in T position, palms facing up Inhale: open arms to a T position Exhale: adduct arms to perpendicular and continue drawing them in until you are hugging your torso reaching the fingertips to the medial part of the scapulae. Repeat x5 Melissa Macchione Student Paper 12

15 Conclusion This program is designed to meet the specific needs of my postnatal client. The program gets my client moving again (safely) while strengthening her body. Progression of her program will be looked at a per session bases. It is important to note that after a client has passed the 6week postpartum period and has been cleared by her physician to go back to her prepregnancy exercise routine, the return should be gradual. Pay close attention to her subjective and objective responses to exercise. Although most of the physiological and morphological changes are most notable for the first 4 6 weeks postpartum, many experts agree that the muscles, tendons and joints do not return to their pre- pregnancy state for at least 9 12 months (ACOG 1994a). 1 When designing a post- partum exercise program, if you are unsure of the exercises you have chosen for your client, get your plan approved by your client s physician. Keeping an open dialogue with the physician is also a great way to ensure you are progressing the program safely. And of course, simply asking your client how she is feeling during and after her sessions will give you the best feedback. 1 Pregnancy and PostPartum Exercise Melissa Macchione Student Paper 13

16 Bibliography Books: Isacowitz, Rael. Study Guide: Comprehensive Course. Costa Mesa, California: Body Arts and Science International, STOTT PILATES Faculty. Pre-Natal Workshop, Toronto, Ontario: Merrithew Corporation, STOTT PILATES Faculty. Post-Natal Workshop, Toronto, Ontario: Merrithew Corporation, Articles: Lee, Diane Diastasis Recti Abdominis and the Implications for Returning to Sport after Pregnancy, In Touch Summer, Websites: Bloom, Erika Training the Pre and Postnatal Pelvic Floor, Pilates Style, WebMD Faculty Abdominal Separation (Diastasis Recti), WebMD, Logan, Catherine Pregnancy and Postpartum Exercise IDEA Health & Fitness, Images: Common PostPregnancy Postural Google images Diastasis Recti Abdominis Melissa Macchione Student Paper 14