Pregnancy & Physiotherapy

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　The pregnacy year:

First Trimester
1-12 weeks
Formation of baby’s major body organs
Second Trimester
13-27 weeks
Increasing growth, Uterus near the rib cage
Third Trimester
28-40 weeks
Continued growth and maturation of body systems
Postnatal
0-3 months
6 weeks for uterus to normalise

Changes and Challenges

Hormonal
Cardiovascular
Posture
Musculoskeletal and Biomechanical

Hormonal

Progesterone increases
Breast development
Reduction in smooth muscle tone - leads to constipation/haemorrhoids
Hyperventilation
Increased storage of fat
　
Oestrogen Increases
Increase growth of uterus and breast ducts
Prepares breasts for lactation
Increases water retention
Relaxin Increases
Decreases intrinsic strength of connective tissue (Mantle et al , 2004)

Cardiovascular

Blood volumes increase by 40%
Haemoglobin levels drops by 20%
Heart size increases by 30-50% to cope with increased blood volume
Enlarged uterus limits descend of diaphragm
Increase in resting Respiratory Rate (15-18 bpm)

Posture

Forward shift of Centre of Gravity (COG)
Increase in lumbar and thoracic curves

Biomechanical Changes

Forward shift of COG
Lower ribcage flares
Pectorals tighten
Rectus abdominus (6 pack muscles) lengthens
Illiopsoas (hip flexors)shorten
Pelvic floor muscles stretch
Glut max (buttock) lengthens
Lumbar extensors shorten

Weight Gain

Average weight gain 12-13 kg
Blood volume 1.2kg
Enlarged breasts 0.5kg
Uterus and contents 5.6kg
Fat deposits 4.0kg
Fluid 1.2kg

Common Musculoskeletal (MSK) Problems

Low back pain - 76%
(Pennick and Young, 2007)
Pelvic Girdle Pain (PGP) 14-22%
(Owens et al, 2002)
Rectus Abdominus Diastasis (RAD) (separation of the muscle)
Meralgia Parasthetica (pinching of the outer thigh nerve causing numbness in outer thigh)
Carpal Tunnel Syndrome
Incontinence

Causes of Low back pain

Increased lumbar lordosis (arch in lower back)
Altered posture
Lax ligaments
Lengthening abdominal musculature
(Pennick and Young, 2007)


Pelvic Girdle Pain - PGP

Associated with pregnancy/postpartum period
Pain, instability and dysfunction of the:
Pubic symphysis
One or both Sacroiliac joints
Associated lumbar pain
14-22% will describe SEVERE symptoms

Distribution of Pain

Pubic symphysis
Groin
Inside thighs
Perineum
Coccyx (tail bone)
One or both Sacroiliac joints

Causes of PGP

Lots of factors:
Hormonal softening of connective tissue
Postural Changes
Altered activity in the supporting muscles
Asymmetrical alignment of the pelvic joints

Assessment and Treatment

Full Physiotherapy assessment
Posture re-education
Advice e.g. transfers, gait, exercise
Home exercise programme
Manual techniques
Additional aids

Common Dysfunctions

Pubic symphysis
Anterior/posterior
Superior/Inferior
Ilium (innominate)
Upslip/downslip
Rotation
Sacrum
Side-bent
torsion

Treatment


Postural Correction
Gait re-education
Stabilizing musculature - Transverse abdominus, Gluteus medius
Using the above functionally



Manual Techniques

Pregnancy is not a contraindication for manual techniques
Grade 3-4 mobilisations
Hold-relax techniques
Proprioceptive taping
　
　

Summary to Pelvic Girdle Pain (PGP)

Improvement is usually seen within 2 treatment sessions
Usually pain free within 6 weeks postnatally
Quicker the treatment, better the prognosis
Manual techniques

Rectus Abdominus Diastasis (separation of muscle)

Linea Alba - centre point between the 2 sides
Normally Rectus Abdominus (RA) run parallel to each other
RA stretch and separate during pregnancy
Greatest stretch around umbilicus (belly button)
Gap can increase up to 20cm

Problems associated with RAD

Looks unslightly, esp in slimmer women
‘pot belly effect’
Can develop herniation
Reduced efficiency of abdominals

Treatment

Prevention of worsening RAD in pregnancy
Modification of daily activities
Trans Abs, Obliques, Rectus Strengthening
Needs to be progressive
Start at very basic isometric contraction
Tubigrip can sometimes help


Meralgia Parasthetica

Lateral Femoral Cutaneous Nerve (LFCN)
Lumbar spine: L2/3 origin
No motor component - purely sensory
Parasthesia (abnormal sensation)of upper lateral thigh
Hyper-sensitivity to pain
Motor strength normal
Usually on prolonged standing/walking
More common in pregnancy and obese population


Treatment

Postural work - avoid sway
Adapted sleeping postures to reduce compression
Sometimes psoas (hip flexor) stretch can help
Active range of movement exercises for lumbar spine



If you are having any issues then as you can see Physiotherapy can help and you should book in for an assessment

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