Top tips and exercise favourites to help women thrive physically and emotionally from conception to delivery

Transcription

1 Exercising for two Top tips and exercise favourites to help women thrive physically and emotionally from conception to delivery Lisa Westlake PRE-NATAL EXERCISE Pregnancy is an exciting time, involving many physical, emotional and social changes. Sensible exercise is beneficial for healthy pre and postnatal women. It is absolutely vital, however, that they exercise at appropriate levels without compromising the wellbeing of their baby or themselves. The general changes associated with pregnancy have programming implications. In addition, some women experience pregnancy related conditions, which may further influence their exercise choice. Helping women reap the benefits of staying fit and active in the childbearing year is rewarding. Our role is to guide them, at all times, in order to ensure safety, appropriate choice and good technique. To safely design exercise programs for pre and post natal women, instructors need to understand the physical and psychological consequences of pregnancy, plus problems that can occur, and their programming implications. Benefits of exercising during pregnancy Appropriate exercise provides physical and psychological benefits: Maintenance of general strength, fitness and health during pregnancy Assist physical and psychological progression through pregnancy Healthy body weight Awareness of body, posture and changes that are occurring over time Enhance healthy progression of pregnancy Mood, morale and self esteem Prevention of potential problems that can be associated with pregnancy Allow women to continue exercise in the presence of various problems. Assist preparation for labour and early motherhood. Recovery after labour and return to pre-pregnant weight and body shape Social interaction and emotional support 1 1

2 Important considerations Exercise and pregnancy guidelines Individual Frequency 3-6 sessions per week (Vary) Intensity Mild to moderate perceived exertion Time CV intensity and time require balance Style Vary, mix CV and strength, Strength General Pregnancy specifics Type Non contact after first trimester Conditions Avoid aggravating moves / positions Add exercises that will assist Provide ongoing fitness without aggravating Each pregnancy is different and the stages of pregnancy have varied exercise implications. Comprehensive assessment Ongoing review Individual programming Monitor closely Provide modifications Ongoing advice and education Exercise intensity and duration The foetus is dependent on mother for disposal of heat so it is recommended to avoid overheating, particularly in the first trimester during organ formation. Some studies have demonstrated a connection between exercise intensity and low birthweight or early delivery Avoid intensity and duration that causes women to feel very hot, sweaty, exhausted RPE Scale 0 20 work at 13 / 14 Consider both duration and intensity CV exercise mins at mild to moderate intensity Do not exercise with a fever and avoid saunas, sun baking, etc Ensure adequate hydration and consider environment 2 2

3 Pelvic floor During pregnancy there is an increased load and stress on the pelvic floor which creates a risk of short or long-term incontinence or prolapse. PF care and muscle training should be a priority during pregnancy and is very significant in programming considerations Pelvic floor integrity is compromised Pregnancy and child birth Constipation Heavy lifting Chronic coughing Age Obesity Menopause Poor posture and Chronic back pain Inappropriate exercise Specific to pregnancy Stress incontinence Increased Load on PF (weight of baby) Bounce / jolt Strain / increased IAP Prolonged standing Symptoms Accidental leakage: coughing, laughing, sneezing, exercising Needing to rush to the toilet Going often just in case Problems with wind and bowel control Dragging or heaviness Decreased sexual sensation During pregnancy and post-partum the pelvic floor must take high priority Avoid increased risk by adding extra stress/ jolting / bouncing the pelvic floor Educate women about the importance of pelvic floor exercises Incorporate pelvic floor exercises in all programs Fast and slow twitch: power and endurance Quality not quantity Ensure correct technique Train for the weakest link Refer 3 3

4 Abdominals The abdominal wall shape, strength and integrity will alter as the pregnancy develops. Altered mechanics, supine hypotension and risk of rectus diastasis are three reasons abdominal exercises should be modified. Abdominal Muscles and Pregnancy Altered abdominal mechanics, strength and function Potential for back pain due to decreased spinal support and abdominal wall integrity Risk of supine hypotension Increased abdominal tension in supine > increases IAP Tendency for Rectus Diastasis (separation of RA) Rectus Diastasis Abdominus Separation of Rectus Abdominus at some point along the linear alba, 66% in 3 rd trimester Excessive RA work will increase the risk and amount of separation Leads to decreased muscular support to spine and abdominal contents Thus abdominal curls and crunches are not recommended even in early pregnancy Causes Close pregnancies Large baby or twins Successive pregnancies without recovery of abdominal tone Overuse of abdominals against resistance during pregnancies Genetic predisposition Hormones (relaxin and Progesterone) Exercise considerations Select alternatives to supine abdominal curls after 16 weeks Focus on posture and TA / core focus is important and beneficial throughout pregnancy and after delivery Avoid excessive abdominal training, even early, in all positions Core recruitment and abdominal alternatives are performed in various positions including sitting, standing, 4 point kneeling, at the wall and side lying. 4 4

5 Joint laxity, posture and back health Increased risk of joint pain or injury during pregnancy because Weight gain Postural changes Increased load Joint laxity Altered balance Low back and pelvis particularly vulnerable Other joints at risk include feet, wrists, and thoracic spine Spinal alignment and load Natural spinal curvature and spinal stabilisation are challenged as the pregnancy progresses leading to a pregnant woman being vulnerable to lower back ache and associated problems. Typically the areas of concern are lumbar spine during pregnancy and neck and thoracic spine during early motherhood. Altered body shape & weight distribution > Shift of centre of gravity (COG) forward in second and third trimesters Stretched and weakened abdominals Altered mechanics of outer abdominals Weakened quadriceps Anterior pelvic tilt, Increased lumbar lordosis, Thoracic kyphosis, Cervical lordosis Compromised posture and stability Potential pain and injury Exercise can exacerbate or prevent pain and risk of injury Avoid high impact, jerking and jolting, extreme range of movement, and complex choreography. Educate regarding static and dynamic posture Encourage natural spinal curvature (spine, pelvis and shoulder girdle) Incorporate postural cues. Focus on spinal and scapular stability Utilise positions that relieve load such as four point kneel Modify exercises and decrease load and stress on spine. Incorporate lumbar mobility and rhythmical movements Incorporate posterior muscle strengthening Anterior muscle flexibility Fitball, aqua exercise and modified pilates are all ideal options for back health promotion Refer 5 5

6 Pregnancy related pelvic joint pain 80% pregnant women suffer some degree of back or pelvic joint pain. Movement at the Pubic symphysis and sacroiliac joints leads to inflammation and pain. Symptoms range from intermittent, mild discomfort to being unable to walk without aid. Severe cases report feelings of joint movement and pain significantly limiting function. Pain may be local or referred. It is important to recommend referral for assessment and diagnosis before continuing exercise, as inappropriate programming will exacerbate symptoms. Muscle imbalances and compromised core stability Inflammation, instability and pain Hormonal effect (fluctuates) Increased load Subsequent pregnancies without management / exercise rehabilitation Variable symptoms and severity May persist after delivery Aggravating factors Wide stance Repetitive weight transfer L>R Walking, Stairs / stepping Prolonged standing Rotation eg rolling in bed Asymmetrical/ Unilateral weight bearing eg up off floor Asymmetrical carrying eg on one hip Muscle imbalances Compromised core stability Avoid Prolonged standing, Sudden changes in direction High impact Wide stance Single leg stance / asymmetrical load Weight shift side to side Pelvic torsion /rotation Steps, stairs 6 6

7 Include Rest Non weight bearing exercise Low impact / low load Narrow base (mini skirt) Emphasis role of stabilising muscles Centering exercises Piriformis stretch Support Refer / Treatment Fitball or aqua provide good alternatives Prevention vs. management Blood flow Supine hypotension Lying supine may create impaired blood flow to the uterus Avoid supine positions after the 16 weeks Avoid slight incline after 30 weeks There are many fabulous alternatives Standing hypotension / impaired venous return During later pregnancy the heavy enlarged uterus may impair venous return in the upright position without the assistance of muscle pump. Beware of muscle conditioning in standing and encourage muscle pump Take care / avoid prolonged stationary standing especially after aerobic exercise Preparation for labour and motherhood, relaxation Labour preparation : planning, education, physical and emotional preparation 7 7

8 Exercising for two; practical applications Main considerations Contraindications and precautions Psychological As well as physical Individual ongoing assessment, modifcations Intensity Mild to moderate perceived exertion Blood flow Supine and stationary standing Pelvic floor minutes C.V. Abdominals avoid supine, raised intraabdominal pressure and rectus load DRAM Core Posture, back and joints Core control, exercise choice, avoid overload, releive PRPGP Avoid causing or exacerbating Labour preparation optional Rest and relaxation Practical applications Include Low impact, low load exercises Walking, cycling, swimming Appropriate strength exercises: general and specific Pelvic floor exercises Postural strength, upper back Narrow base/ mini skirt and Centering Quadriceps Pelvic and spinal mobility Abdominal / core stabilising Modified Fitball, Aqua and Pilates are all great additions or alternatives Positions to relieve load and lumbar lordosis Mobility and flexibility Relaxation Referral Avoid High impact, intensity or load Stationary standing Supine and prone positioning Loading vulnerable or affected joints 8 8

9 1 Mobility Standing, seated and kneeling lumbar, thoracic, cervical and scapular mobility 2 Pelvic floor muscle training What Why Where When (home routine, daily activities, exercise) Variety of teaching techniques and cues Positioning and posture In all positions Long spine Natural curvature Relaxed Technique PFM recruitment PFM relaxation Long holds Quick lifts Unwanted extras Breathing Cueing / terminology 9 9

10 At the Wall 3 Wall squat + Calf raises + upper limb strengthening 4 Wall push ups + Wall hover / all fours / hover core alternatives 5 Seated Upper limb + posture /core (recruitment and training) Lateral raise Row Triceps Posterior Seated obliques

11 6 Seated semi squat + Seated obliques 7 All fours Abdominals / Core and posterior muscle strengthening + Rectus reminder

12 Test for rectus diastasis: lie in supine position, knees bent, palpate along midline whilst raising head and shoulders. Feel for gap or bulge. 8 Bridging Ball or floor 9 Labour preparation Breath Body part relaxation Acknowledge but move Visualisation Moving, clapping, music Focus on baby Between contractions Positive affirmations 10 Mobility, flexibility, relaxation

13 FURTHER READING Allen RE, Hosker GL, Smith ARB, Warrell DW. Pelvic floor damage and childbirth: a neurophysiological study. Br. J. Obst Gynecol Sept 90, vol 97, Baker, C Pregnancy and Fitness, A and C Black, London Brown S, Lumley J. Maternal Health after childbirth: results of an Australian population based survey. Br. J. Obst and Gynecol. Feb 1998, Vol Bullock Saxton J. Musculoskeletal changes in the prenatal period. Women s Health, a text book for physiotherapists. WB Saunders Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obst Gynecol 1998 Vol 175 Dimpfl Th, Hesse U, Schussler B. Incidence and cause of post partum urinary stress incontinence. Eur J Obst Gynecol 43, Millard R. Risk factors for urinary incontinence in women. Aust Continence Journal, Dec Sapsford R Womens Health, A text book for physiotherapists. WB Saunders Co LTD London 1998 Snooks SJ, Swash M, Mathers SE and Henry MM. Effect of vaginal delivery on the pelvic floor: a 5 year follow up. Br.J.Surg. 1990, vol 77 Dec, Snooks J, Swash M, Henry MM and Setchell M. Risk factors in childbirth causing damage to the pelvic floor innervation. Br J Surg. Vol 72, Sept 1985 S15 - S17 Physiotherapy in Obstetrics and Gynaecology. Ch 7, The Post Natal Period. Westlake, L Westlake, L Westlake, L Westlake, L Exercising for two, Hachette Mums shape up, Hachette Strong to the core, ABC books Strong and Stable, ABC books Wilson PD, Herbison GP A randomized controlled trial of pelvic floor muscle exercises to treat post natal urinary incontinence. Int Urogynecol :