Kelly Feddema, PT, PRPC returns in a guest post on Pregnancy Associated Ligamentous Laxity. Kelly practices pelvic floor physical therapy in the Mayo Clinic Health System in Mankato, MN, and she became a Certified Pelvic Rehabilitation Practitioner in February of 2014. See her post on diastasis recti abdominis on the pelvic rehab report, and learn more about evaluating and treating pregnant patients by attending Care of the Pregnant Patient!
Pregnancy associated ligamentous laxity is something that we, as therapists, are fairly well aware of and see the ramifications of quite often in the clinic. We know the female body is changing to allow the mother to prepare for the growth and birth of the tiny (or sometimes not so tiny) human she is carrying. We also know that the body continues to evolve after the birth to eventually return to a post-partum state of hormonal balance. Do we think much about what this ligamentous laxity can mean during the actual delivery? Does laxity predispose women to other obstetric injury?
A recent study in the International Urogynecology Journal assessed ligamentous laxity from the 36th week of pregnancy to the onset of labor by measuring the passive extension of the non-dominant index finger with a torque applied to the second metacarpal phalangeal joint. They collected the occurrence and classification of perineal tears in 272 out of 300 women who ended up with vaginal deliveries and looked for a predictive level of second metacarpophalangeal joint (MCP) laxity for obstetric anal sphincter injury (OASI). They concluded that the increased ligamentous laxity did seem associated with OASI occurrence which was opposite of their initial idea that more lax ligaments would be at less of a risk of OASI.
Today's guest post comes to us from Kelly Feddema, PT, PRPC. Kelly practices pelvic floor physical therapy in the Mayo Clinic Health System in Mankato, MN, and she became a Certified Pelvic Rehabilitation Practitioner in February of 2014. To learn more about diastasis recti abdominis, consider attending Care of the Postpartum Patient!
It can be a struggle to treat patients with diastasis recti if they don't seek treatment early after giving birth. Many therapists may often find themselves thinking “if I only could have started them sooner.” Why does this condition often get missed at postpartum examinations? I personally deal with symptoms from an undiagnosed diastasis, and I'm a therapist! I didn’t really pay attention to it until I started down the road of becoming a pelvic floor therapist.
Diastasis recti can be a difficult diagnosis to treat, as the patient may come to us when they are already one year postpartum, and not everyone agrees on the what are the best treatments. To crunch or not crunch? To use a brace or not to brace? It would be great if we had a similar healthcare system to France, where the norm is to have 10-20 postpartum rehabilitation visits with women after child birth. While therapy is available in the United States, women must ask for it.
As practitioners, we understand the value of a yoga practice for multiple systems. Yoga improves cardiovascular function, pulmonary function, improves flexibility, builds strength, improves balance, and cultivates resiliency. Prenatal yoga is deemed safe and widely practiced. Beyond not laying prone after the first trimester, what are modifications for practicing yoga while pregnant? Is there any evidence to demonstrate if specific yoga postures are safe from both the maternal and fetal perspective?
Polis et al set out to determine the safety of specific yoga postures using vital signs, pulse oximetry, tacometry, and fetal heart rate monitoring. The patients were diverse in age, race, BMI, gestational age, parity, and yoga experience. Exclusionary criteria included preeclampsia, placenta previa, bleeding in the 2nd or 3rd trimester, gestational diabetes, BMI greater than 35 and other medical conditions that presented contraindications.
The maternal and fetal responses were tested in 26 yoga postures. The selected postures, much like most yoga classes, offered a variety of physical positions. The standing, seated, twists and balancing postures chosen were: Easy Pose, Seated Forward Bend, Cat Pose, Cow Pose, Mountain Pose, Warrior 1, Standing Forward Bend, Warrior 2, Chair Pose, Extended Side Angle Pose, Extended Triangle Pose, Warrior 3, Upward Salute, Tree Pose, Garland Pose, Eagle Pose, Downward Facing Dog, Child’s Pose, Half Moon Pose, Bound Angle Pose, Hero Pose, Camel Pose, Legs up the Wall Pose, Happy Baby Pose, Lord of the Fishes Pose and Corpse Pose.
On my son’s due date, I ran 5 miles (as I often did during my pregnancy), hoping he would be a New Year’s baby. The thought of low bone density never crossed my mind, even living in Seattle where the sun only intermittently showers people with Vitamin D. However, bone mineral density changes do occur over the course of carrying a fetus through the finish line of birth. And sometimes women experience a relatively rare condition referred to as pregnancy-related osteoporosis.
Krishnakumar, Kumar, and Kuzhimattam2016 explored vertebral compression fracture due to pregnancy-related osteoporosis (PAO). The condition was first described over 60 years ago, and risk factors include low body mass index, physical inactivity, low calcium intake, family history, and poor nutrition. Of 535 osteoporotic fractures considered, 2 were secondary to PAO. A 27-year-old woman complained of back pain during her 8th month of pregnancy, and 3 months postpartum, she was found to have a T10 compression fracture. A 31-year-old with scoliosis had back pain at 1 month postpartum but did not seek treatment until 5 months after giving birth, and she had T12, L1, and L2 compression fractures. The women were treated with the following interventions: cessation of breastfeeding, oral calcium 100 mg/day, Vitamin D 800 IU/day, alendronate 70 mg/week, and thoracolumbar orthosis. Bone density improved significantly, and no new fractures developed during the 2-year follow up period.
Nakamura et al.2015 reviewed literature on pregnancy-and-lactation-associated osteoporosis, focusing on 2 studies. The authors explained symptoms of severe low back, hip, and lower extremity joint pain that occur postpartum or in the 3rd trimester of pregnancy can be secondary to this disorder, but it is often not considered immediately. A 30-year-old woman with such debilitating pain in her spine with movement 2 months postpartum had to stop breastfeeding, and 10 months later, she was found to have 12 vertebral fractures. She had low bone mineral density (BMD) in her lumbar spine, and she was given 0.5mg/day alfacalcidol (ALF), an active vitamin D3 analog, as well as Vitamin K. No more fractures developed over the next 6 years. A 37-year-old female had severe back pain 2 months postpartum, and at 7 months was found to have 8 vertebral fractures due to PAO. Her pain subsided after stopping breastfeeding, using a lumbar brace, and supplementing with 0.5mg/day ALF and Vitamin K. The authors concluded goals for treating PAO include preventing vertebral fractures and increasing BMD and overall fracture resistance with Vitamins D and K.
So many physiological changes occur to a woman’s body during pregnancy, it is no wonder that pregnant women have back and lower extremity aches and pains. These women experience hormonal changes, weight gain, reduced abdominal strength, and their center of mass shifts anteriorly. These physiological changes result in altered spinal and pelvic alignment, and increased joint laxity. Also, many women report increases in size of their feet and a tendency to have flatter arches during and after pregnancy. Alignment changes may influence pain. Altered alignment could change the physical stresses placed upon different tissues of the body, which that specific tissue was not adapted to, therefore, causing pain or injury to that tissue.
A recent study published in 2016, in the Journal of Women’s Health Physical Therapy1, investigated if there may be a relationship between anthropometric changes of the foot that occur with pregnancy, and pregnancy related musculoskeletal pain of the lower extremity. The study included 15 primigravid women and 14 weight matched controls. This study was a repeated-measurements design study, where the investigators measured foot length, foot width, arch height index, arch rigidity index (ARI), arch drop (AD), rear foot angle, and pelvic obliquity during the second and third trimesters and post-partum. The subjects were surveyed on pain in the low back, hips/buttocks, and foot/ankle.
The author’s findings were that measures of arch flexibility (ARI and AD) correlated with pain at the low back and the foot and ankle. They concluded that medial longitudinal arch flexibility may be related to pain in the low back and foot. The more flexible arches were associated with more pain in the study participants. They reported the participants in their study did not have very high pain levels in general, and recommend further studies to compare pregnant women who experience severe pain with women who do not while comparing their alignment factors. This article is a good reminder for physical therapists to consider the changes that occur to the foot including changes in arch height, arch flexibility, and foot size and how that influences the pelvis and lower extremity for prevention and treatment of musculoskeletal pain during pregnancy.
Preterm birth can have deleterious health effects not only for the child, but also for the mother. A child may be born so early that various health systems are not matured, leading to susceptibility and delay in development and growth. Maternal health may also be severely impacted, with conditions such as anxiety and psychological stress. Managing the prevention of a pre-term delivery can be stressful and challenging for a pregnant woman, and authors Ha & McDonald (2016) report that this issue is not well studied. A cross-sectional survey was completed to find out not only what a woman’s preferences and concerns are, but also to find out which recommendations were likely to be followed by the patient. This is important, the authors state, because women who are actively involved in medical decisions are more likely to feel satisfied with their childbirth experience.
The survey was completed by 311 women at a median of 32 weeks gestation. Mean age was 30.9, and the majority of them identified as European/White-Caucasian. Most of them were married or in a common-law relationship and had received some level of post-secondary education. The majority of women who were told they were at increased risk of preterm labor (PTL) preferred close-monitoring rather then PTL prevention. Of interest is that the majority of women reported they would use other sources of information besides their primary provider, with the most reported source being the internet or family and friends. This point begs the question of how high is the quality level or accuracy of the available information on the internet or in the general public? Common available options for prevention included progesterone, cerclage, and pessary use. If a woman is not interested in using recommended prevention strategies, the goal of the rehabilitation clinician should be to, on a constant basis, monitor for symptoms and signs of early labor, and encourage the patient to keep any recommended provider appointments, and stay in close contact with her provider so that close-monitoring may be carried out.
An additional goal for rehabilitation is to provide the mother with strategies that may assist her in managing her anxiety, stress, movement dysfunctions, sleep, and other activities. Prior research has validated the benefits of relaxation training in pre-term labor: a cost-effective, low risk and easily implemented strategy. Training women in such a tool during pregnancy fits well into the rehab provider’s scope, and can be instructed in the clinic (or home!) for home program implementation. Larger newborns, longer gestations, and higher rates of prolonged gestations have been recorded when using relaxation training training for pre-term labor.Janke et al., 1999) Chuang et al. (2012) have documented fewer admissions to neonatal intensive care unit, decreased rates of extreme pre-term birth, and shorter stays in hospital with use of relaxation training. Meditation, mindfulness, deep breathing, visualization, and movement within recommend medical limits may all be valuable tools that make up a part of a patient’s rehabilitation experience. In an article describing how prenatal meditation influences infant behaviors, yoga, singing, and massage therapy are all cited methods for improving maternal and/or fetal health.Chan, 2014
“To me it felt like I was just sitting on bed rest, waiting to have a seizure, you know, waiting to start circling the drain.” “Every time I went to the doctor I had this…anxiety attack.” These are the words of pregnant women diagnosed with preeclampsia and on bed rest. Other phrases reported by the authors who interviewed women on bedrest included “…an impending doom…”, “…meltdown…”, “nervous wreck.” A few of the major themes that emerged in the interviews was that of negative thoughts and feelings, family stressors, and not being heard. And while using the term “crazy” is not truly appropriate, women who are forced to abruptly stop interacting and participating in their typical life activities must be regarded as being very high risk for more than just physical issues. Kehler et al., 2016
In an ideal situation, bed rest during pregnancy is prescribed to help keep the mother and fetus healthy. Unfortunately, bed rest in itself is associated with potentially negative consequences in physical and mental health, and providers are not always up-to-date on changing recommendations for bedrest. Perhaps the cautious attitude of providers towards minimizing risk guides some choices. In addition, many women describe frustration about lack of clear guidelines, difficulty managing their stressful feelings, and varying degrees of support from medical providers.
During pregnancy-related bed rest, research has described how the entire family is affected. Physically, the mother may have changes in her circadian rhythms, increased anxiety, depression, and hostility. The rest of the family can also experience and demonstrate stress. Other children may act out, partners may be more stressed and worried, and financial strain may be a concern. Bigelow & Stone, 2011 Although we as rehab professionals may not have solutions for every issue, we may be able to facilitate accessing resources and at a minimum hear what a woman is dealing with during this stressful time. Many women, even when on bedrest, are allowed to attend medical appointments such as physical therapy, and should be provided with appropriate physical and mental activities to help minimize muscle atrophy and stress. Home health or hospital-based providers are also in a perfect position to educate providers on the value of referrals while the patient is at home or in the hospital.
During labor, I had no problem breathing out. My hang up came when I had to inhale - actually oxygenate my blood and maintain a healthy heart rate for my almost newborn baby. When extra staff filled the delivery room, and an oxygen mask was placed over my face, my husband remained calm but later told me how freaked out he was. He was watching the monitors that showed a drop in my vitals as well as our baby’s. In retrospect, I wonder if practicing yoga, particularly the breathing techniques involved with pranayama practice, could have prevented that moment.
A research article by Critchley et al., (2015) broke down breathing to a very scientific level, determining the consequences of slow breathing (6 breaths/minute) versus induced hypoxic challenges (13% inspired O2) on the cardiac and respiratory systems and their central neural substrates. Functional magnetic resonance imaging measured the 20 healthy subjects’ specific brain activity during the slow and normal rate breathing. The authors mentioned the controlled slow breathing of 6 breaths/minute is the rate encouraged during yoga practice. This rate decreases sympathetic activity, lessening vasoconstriction associated with hypertension, and it prevents physiological stress from affecting the cardiovascular system. Each part of the brain showed responses to the 2 conditions, and the general conclusion was modifying breathing rate impacted autonomic activity and improved both cardiovascular and psychological health.
Vinay, Venkatesh, and Ambarish (2016) presented a study on the effect of 1 month of yoga practice on heart rate variability in 32 males who completed the protocol. The authors reported yoga is supposed to alter the autonomic system and promote improvements in cardiovascular health. Not just the breathing but also the movements and meditation positively affect mental health and general well-being. The subjects participated in 1 hour of yoga daily for 1 month, and at the end of the study, the 1 bpm improvement in heart rate was not statistically significant. However, heart rate variability measures indicated a positive shift of the autonomic system from sympathetic activity to parasympathetic, which reduces cortisol levels, improves blood pressure, and increases circulation to the intestines.
The following testimonial comes to us from Karen Dys, PTA. Karen recently attended the Care of the Pregnant Patient course, and she was inspired to send in the following review. Thanks for your contribution, Karen!
I have been working as a physical therapist assistant for 11 years and worked in a variety of settings. In the past two year I have become more focused on pelvic floor rehabilitation. During that time frame I have had a handful of pregnancy patient including being a pregnant woman myself. Since taking this course, my mind has been opened up of how I can treat my patients and educate them for their best future outcomes. I also can see now how I would have benefited myself if I knew some of these techniques that I’ve now learned. With knowing with my personal story and that my PT could have helped me more with avoiding bed rest and staying active longer with pregnancy, it has become my goal now to treat my pregnant patients differently. I am thankful for Herman and Wallace courses to gain these wonderful techniques to reach out and help so many people.
Within the first few moments of meeting the teacher at a continue education class I can tell if is going to be a good class or not. This course started out great with a very friendly and kind person. Sarah’s compassion and knowledge brightly shined throughout the weekend of teaching. It was very refreshing having a teacher who also has experienced some of the same problems are patients go through. It gave it a good personal perspective of how we can affect our patient outcomes.
You wouldn't place a newborn in a crib without knowing the legs were firmly attached at the right angle to the base. You wouldn't jump on a hammock if the poles or trees were not firmly intact and upright to support the sling. Why would you treat a pregnant woman without checking if her hips were working optimally in proper alignment to support the pelvis, inside which a new life is developing? Let's hope higher level clinicians spend the extra effort to learn about the surrounding areas that affect our specialty, whether it is pelvic floor or spine or sports medicine.
In 2015, Branco et al., published a study entitled, “Three-Dimensional Kinetic Adaptations of Gait throughout Pregnancy and Postpartum.” Eleven pregnant women voluntarily participated in this descriptive longitudinal study. Ground reaction forces (GRF), joint moments of force in the sagittal, frontal, and transverse planes, and joint power in those same 3 planes were measured and assessed during gait over the course of the first, second, and third trimesters as well as 6 months post-partum. The authors found pregnancy does influence the kinetic variables of all the lower extremity joints; however, the hip joint experiences the most notable changes. As pregnancy progressed, a decrease in the mechanical load was found, with a decrease in the GRF and sagittal plane joint moments and joint powers. The vertical GRF showed the peaks of braking propulsion decreases from late pregnancy to the postpartum period. A significant reduction of hip extensor activity during loading response was detected in the sagittal plane. Ultimately, throughout pregnancy, physical activity needs to be performed in order to develop or maintain stability of the body via the lower quarter, particularly the hips.
The same authors, in 2013, studied gait analysis in the second and third trimesters of pregnancy. Branco et al., performed a 3-dimensional gait analysis of 22 pregnant women and 12 non-pregnant women to discern kinetic differences in the groups. Nineteen dependent variables were measured, and no change was noted between 2nd and 3rd trimesters or the control group for walking speed, stride width, right-/left-step time, cycle time and time of support, or flight phases. Comparing the 2nd versus 3rd trimester, a decrease in stride and right-/left-step lengths decreased. The 2nd and 3rd trimesters both showed a significant decrease in right hip extension and adduction during the stance phase when compared to the control group. In this study, the authors also noted increased left knee flexion and decreased right ankle plantar flexion during gait from the 2nd to the 3rd trimester. The bottom line in this study, just as the more recent one suggests, pregnant women need a higher degree of lower quarter stability to ambulate efficiently throughout pregnancy.