Chapter 14
Therapeutic Exercise in
Obstetrics
Copyright 2005 Lippincott Williams & Wilkins
Why Therapeutic Exercise for Pregnant
Women?
 Primary conditions unrelated to
pregnancy
 Disorders related to physiologic
changes during pregnancy
 Physical and psychological benefits
 Preventative measures
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Physiologic Changes Related to
Pregnancy – Support Element
Endocrine system – Alterations in hormone
levels, GI function, etc.
CV system – Changes in blood volume,
hemoglobin levels, vasodilation.
Respiratory system – Increased mucus in
respiratory tract, predisposition to
coughing, sneezing if pelvic floor and
associated muscles are weak.
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Physiologic Changes Related to Pregnancy
Base Element
Musculoskeletal symptoms should not be
considered normal.
 COG shifts forward and upward (lumbar
lordosis, forward head posture, rounded
shoulders, etc).
Changes in hormone – Joint laxity
(increased foot pronation).
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Therapeutic Exercise Intervention
for Wellness
Moderate aerobic exercise (carefully monitored
and prescribed) is safe and beneficial for the
mother and fetus.
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Exercise Intensity Guidelines
 In pregnancy, maternal resting HR is
elevated over nonpregnant values by 15–20
bpm.
 Mitral valve prolapse occurs more frequently
during pregnancy and may be aggravated
by heart rates above 140 bpm.
 Therefore, reduce exercise intensity by 25%
to 60–75% to be safe.
 A maximum HR of 140 bpm for novice
exercisers and 160 bpm for experienced
exercisers.
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Activities to Avoid
Horseback riding
Snow and water
skiing
Snow boarding
Ice skating
Diving
Bungee jumping
Heavy weight lifting
High-resistance
activities
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Therapeutic Exercise for Common
Impairments
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Adjunctive Interventions
Hot packs – Safe for back, neck,and
extremities.
Ultrasound – Sites away from uterus.
Ice – Used on joint pain and
inflammation.
NMES/TENS – Contraindicated
(except for TENS during labor and
delivery).
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Impaired Muscle Performance
Abdominal Strength
Goal – Improve muscle balance, posture, support
of uterus via pelvic floor, stabilization of trunk
and pelvis via lumbopelvic core.
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Exercise Examples
 Supine hip and knee flexion with hip
abduction and lateral rotation.
 Progressive heel slides.
 External oblique exercises to counter
anterior pelvic tilt in variety of positions.
 Concentric and eccentric abdominal
contractions in quadruped.
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Quadruped Abdominal Exercise
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Pelvic Floor Strength
Importance cannot be overemphasized!
Attention to pelvic floor strength should occur early
in the pregnancy and continue throughout the duration
and into postpartum.
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Impaired Joint Integrity and
Muscle Length
Joint Hypermobility
Greater degree of joint laxity
throughout the body during
pregnancy.
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Abdominal Muscle Length
External/internal oblique, transversus
abdominis, rectus abdominis – all
lengthen.
Rectus muscles separate in midline,
creating diastasis recti.
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Diastasis Recti
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Corrective Exercise
1. Patient manually
approximates recti
muscles toward
midline.
2. Performs a posterior
pelvic tilt.
3. Slowly exhale while
lifting head.
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Correction of Diastasis Recti
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Pelvic Floor Muscle Length
If coccyx pain is related to pelvic floor
tension myalgia, pelvic floor
relaxation must be emphasized.
1.
2.
3.
Place hand over anal cleft.
Place middle finger in cleft and other
fingers on buttocks.
Pretend to “pass gas” while feeling for
cleft bulging out against middle finger.
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Impaired Posture
Biomechanical Element
Restore ideal alignment
1.
2.
3.
Lordosis intervention - Frequent inner
core activation in various positions.
Wall abdominal isometrics.
Kyphosis intervention – Facilitate
strengthening to scapular upward
rotators, thoracic erector spinae, stretch
pectoral muscles.
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Pain
Causes Include:




Biomechanical strain from increased body mass and dimension.
Postural changes such as lumbar lordosis creating joint stress.
Aggravation of preexisting conditions.
Muscle fatigue from overload, particularly pelvic floor.
Pregnant Woman are particularly susceptible to:
 Lumbar pain
 Posterior pelvic pain
 Nocturnal back pain
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High Risk Antepartum
 20% of all pregnancies include bedrest
prescription.
 Woman who delay childbearing may expect
a higher incidence of obstetric
complications resulting in bedrest.
 General strengthening, circulation
exercises, and relaxation exercises are
indicated to prevent secondary conditions
as a result of bedrest.
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Therapeutic Exercise Considerations
Improve circulation
Promote relaxation
Avoid increased intra-abdominal pressure by
minimizing abdominal contractions during
exercise and ADLs.
Prevent decreased muscle tone and
deconditioning.
Prevent neuromuscular discomfort.
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Therapeutic Exercise Intervention for
Common Impairments
Nerve Compressive
Syndromes
Common during pregnancy due to:
•
Fluid retention
•
Edema
•
Soft tissue laxity
•
Exaggerated postural changes
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Common Nerve Compression
Syndromes
Intercostal neuralgia
Thoracic outlet syndrome
Carpal tunnel syndrome
Lateral femoral cutaneous nerve entrapment
Tarsal tunnel syndrome
Peroneal nerve compression
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Intercostal Neuralgia
Described as intermittent pain in the
rib cage or chest from flaring of the rib
cage.
Intervention includes spinal
elongation with arms overhead in
supine, sitting, or standing postions,
and trunk sidebending away from the
pain.
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Thoracic Outlet Syndrome
1. Strengthening of upper back and
scapular muscles.
2. Lengthening of pectoral muscles.
3. Support can be provided through good
brassieres and manufactured supportive
devices.
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Carpal Tunnel Syndrome
1.
2.
3.
4.
Decrease hand flexion activities.
Night splints.
Finger mobility exercises.
Look at scapula position and correct
scapula depression.
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Lateral Femoral Cutaneous Nerve
Entrapment
1. Exercises to balance hip muscles.
2. Lying on side to draw uterus away from
compressed side.
3. Soft tissue mobilization techniques for IT
band.
4. Strengthening for underused synergists to
ITB (e.g., posterior gluteus medius).
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Tarsal Tunnel Syndrome
1. Elevation of foot and ankle.
2. Active foot and ankle exercises to
reduce edema and compression.
3. Evening posterior splint.
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Peroneal Nerve Compression
Discourage prolonged squatting during
exercise and delivery.
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Other Impairments
Temporomandibular dysfunction
Patellofemoral dysfunction
Joint discomfort or dysfunction
Varicosis
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Summary
 Many physiologic changes that occur during
pregnancy affect a woman’s ability and
motivation to exercise.
 Adherence to precautions, contraindications,
guidelines, and a safe exercise program can be
established for pregnant women.
 Exercise during pregnancy has many benefits
including prevention or assistance in treatment
of impairments.
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Summary (cont.)
 Therapeutic exercise focuses on key postural
muscles affected by changes during pregnancy.
 High risk pregnancy may require bedrest.
 Specific exercises may be performed and are
beneficial for high-risk patients.
 Therapeutic exercise is beneficial postpartum,
even after cesarean section.
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