The body goes through many adaptations throughout its nine months of pregnancy, all leading up to the triumphant day: the day of the birth. Prior to this day, the new mother will have been steadily losing her body shape and adapting to carrying her newborn child. In today’s society, it is becoming more important to have a good shape and general fitness level, and for many mothers, a race to get fit enough to return to work. And if the mother is not returning to work, the amount of lifting, moving, and demand that will be placed on her body over the following months will require a certain (often HIGHER!) level of fitness. Altogether these factors make the postnatal exercise program vital. The program has to be of an intensity that returns the mother to a level of fitness so she can continue with her new everyday tasks, but also it has to factor in the changes in posture that may make her susceptible to injury.
What the Research Says
Currently there is little research about the change of posture and its potential effects on increased injury rates in postpartum women. Traditionally a potentially posture related pain around the lumbar and pelvic regions has been put down to an epidural during the birth. Both Russell et al. (1997) and Russell and Dundas (1996) have attributed this to a retrospect collection of data and the self-fulfilling prophecies of the mother. The research that is available though does focus around the lower back and pelvis area.
Reynolds (2003) suggested that, “As weight increases, posture changes from upright to a lordotic curve, in which the back forms a ‘hollow’ especially when standing”. Reynolds goes on to state that this may be from the additional weight gain towards the end of pregnancy.
Roche and Hughes (1999) also indicate this posture change, “Postpartum back pain can result from the lumbar lordosis adopted by the mother to compensate for the enlargement of the uterus anteriorly.” Leonard (2002) also agrees with this viewpoint, adding that, “These postural changes will result in muscle imbalances occurring throughout the body during pregnancy as muscles are either overactive or stretched as these postural adaptations take place.”
Specific changes in activity of muscles are put forward by Foti et al. (2002), “The data suggests an increased use of hip extensor, hip abductor, and ankle plantar flexor muscles to compensate for increases in body-mass distribution during pregnancy.” They go on to use this data to suggest that these muscles work hard to keep the gait pattern of the individual the same, and that this may be one of the causes of lower back pain in these individuals.
The same muscles have been linked to the initial stages of Sacroiliac joint pain. Chen et al. (2002) recognized that “ because the SIJ (sacroiliac joint) is part of a kinetic chain, athletes may report a history of ankle, foot, knee, hip or spine injury before the SIJ pain syndrome manifests itself.”
Franke (2003) suggests, “Altered mechanics and/or forces related to the lumbar/pelvic/hip regions may result in pelvic-girdle dysfunction and/or instability, which then may contribute to the development, persistence, or reoccurrence of lower back pain.”
According to Janda (1987), “Multiple factors are inherent in the symptoms of lower back pain. Whatever the underlying cause, pain in the lumbar spine will invariably produce either an acute or chronic impairment of muscle function.”
In order to reduce the chances of LBP in the postpartum exerciser, it is evident that the changes in pelvic position and the altered mechanics of the muscles linking into the pelvis will require some form of correction.
Mens (2000) conducted a study on the role of the diagonal trunk muscles with women who were in persistent pelvic pain after childbirth. He concluded that exercises performed without coaching, to improve strength in the diagonal trunk muscles, had no effect on pain relief. He did suggest, though, that the information tapes that were used to instruct the subjects might have reduced the effectiveness of the exercises.
Guidelines that have been set for postpartum exercise do not specifically include postural strengthening exercises. Instead Davies et al. (2003) suggest that previous exercise can be continued in the postpartum period, but it is advised that the intensity be reduced as the new mother may be suffering from fatigue through the demands of a newborn child. Davies et al also suggested, “Initiation of pelvic floor exercises in the immediate postpartum period may reduce the risk of future urinary incontinence.” This exercise, though, should be considered for the reasons that the deep pelvic muscles are important in assisting in the stabilization of the SIJ. Franke (2003) states that the stabilization of the pelvic girdle, lumbar spine, and hips rely on two important muscle groups: the inner and outer unit. The inner unit, or local stabilizers, includes the multifidus, transverse abdominis, diaphragm and the pelvic floor.
Transverse abdominis, internal and external oblique abdominals, multifidus, and the lumbar erector spine are stated as being the most important of the dynamic stabilizing muscles. Also, the pelvic floor and diaphragm could also be important in stabilizing the back, according to Boyling et al. (1994)
Importantly it is noted that if these muscles are to be trained, then the effects of relaxin must be taken into account. According to Ringdahl (2002), “Ligamentous laxity associated with increased levels of relaxin during pregnancy may increase a woman’s risk of postpartum injury”. Ringdahl (2002) goes on to state that although relaxin levels return to normal within one week, the effects can still be persistent for the following three months.
In order to reduce the chances of injury through posture, it is important to get them exercising. Deyo (1998) stresses the importance of exercise in prevention of lower back pain. He suggests, “No single exercise is best, and effective programs combine aerobics for general fitness with specific training to improve the strength and endurance of the back muscles.” A study by Scannell and McGill (2003) came to the conclusion that “changes in lumbar positions assumed, which increase and decrease passive tissue strain, are possible with training.”
Franke (2003) suggests that from his research an integrated approach using manual therapy, specific exercise, and client education is the best way to reduce the chances of posture relating to lower back and Sacroilliac Joint pain. In order to select these specific exercises, Janda (1987) recommends that the clients are tested initially for impairment of muscle function. Boyling (1994) suggests that to train these muscles back to function, they should go through two and possibly three stages. Firstly, they should be worked isometricaly then isotonically with a gradual increase in load, and finally with fast repetitive movements if required
Today it is becoming more common for women to want to get back into exercise straight after birth. Professionals need to start to look at injuries that could occur through the mother’s posture. Her posture will have changed over the previous nine months, and so it becomes vital to look at the woman as she is, and assess her muscle function before writing her back-to-fitness program. She should be taken from isometric to fast repetition exercises with the emphasis on postural control. Relevant specialists may be used in conjunction with an education program for optimum results.
Application of Conclusion
When the mother has given birth, she should be encouraged back into exercise that will help her correct her posture, as well as participating in a variety of other exercise. Educating the mother to know that she may need to use a range of specialists, especially if she is experiencing lower back pain straight away, is very important. In order to work with these clients, it is important that the professional be skilled in assessment of posture and in collecting muscle length measurements.
Therefore it would be advisable when taking on a new postpartum client, that part of the initial assessment look at control of posture through dynamic movements. Using the PT on the Net resources, such as Gary Gray’s “What is Function?” audio series, or Gray Cooks Reebok Movement Screens would be an ideal way of assessing the movement ability of the new client. It may also be advisable to team up with a local Physiotherapist and offer postpartum screening and exercise recommendations. A sports masseur could also prove useful.
The use of a continuum of exercises that start with isometric exercises to build inner strength would be an ideal initial starting point.
As the client becomes better and more controlled in these exercises, she requires progressing towards more dynamic exercises, until eventually she will reach a point of function.
The progression and start point should be the same as when assessing an average client. Their ability should determine the pace at which they progress. Micro progressions are the key, as the client’s lifestyle will become busier and more energy demanding, with the possibility of sleep deprivation.
Ideally the client will start with you before pregnancy and carry on after giving birth for the best exercise results. Annette Lang delivers a great course on Exercise and Pregnancy, so if you get chance to see this, it would give you the practical edge when training postnatal and postpartum clients.
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- Davies, G.,; Wolfe, L.; Mottola, M.; MacKinnon, C. (2003) Joint SOGC/CSEP clinical practice guideline: exercise in pregnancy and the postpartum period. Can. J. Appl. Physiol. 28(3): 329-341
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