Pain-free Pregnancy? It's possible with proper preparation and early intervention by rehab clinicians.

By Jennifer Romanchick

Pregnancy can be the most exciting time in a woman's life. For 9 months, she plans and prepares, reading book after book, cover to cover, to better understand the miracle that's growing inside her. But for many, the joys of being pregnant are quickly overshadowed by physical discomfort. And unlike labor, this pain announces itself way before the first contraction.

Muscles, ligaments and bones are subject to extreme changes during the months of childbearing and 3 months following birth. These shifts affect posture, strength, flexibility, energy level and general sense of well-being. Physical therapy during and after pregnancy can be instrumental to help women prepare and manage their bodies to avoid disruptive conditions, such as low back pain, sciatica, muscle weakness and incontinence. Common services range from postural re-education, therapeutic exercise and manual therapy to muscle energy techniques and modalities for pain control.

The trick is getting women in the door.

Many clients believe discomfort and pelvic floor issues are a normal part of pregnancy, says Maggi Leise, PT, director of physical therapy at ATI Physical Therapy's Women Serving Women, a two-clinic women's health facility in Naperville, Ill. However, Leise is adamant that this isn't the case.

"Pain is common with pregnancy and postpartum, but it is not normal," she says. In fact, of all the possible conditions a woman experiences during pregnancy, pain is the most disruptive. It can magnify fatigue and reactions accompanying hormonal fluctuations, interfere with daily tasks, mobility and exercise, and limit full participation in prenatal and postnatal activities.

Renat Yaron, MSPT, owner of The Healthy Mom Physical Therapy in New York City, shares Leise's sentiment. "Pain should no longer be considered 'just a part of pregnancy' that needs to be endured," she says. "It can and should be addressed early so that women can be more comfortable during pregnancy, and avoid pain after delivery when caring for a new baby and in subsequent pregnancies."

ADDRESSING THE ISSUES

Many women mistakenly think that pregnancy is a time to stop exercising and moving. But this mentality is outdated, and following such a restrictive regimen can actually be deleterious. Labor is hard work and women should be in good physical condition to cope with the challenges of the process.

"I believe that women who do not exercise regularly, who are obese prior to pregnancy, have poor postural habits, weak pelvic floor muscles, weak abdominal muscles and overall poor body awareness are apt to develop more issues during the stages of pregnancy," says Jennifer R. Whaley, PT, CLT, owner of Physical Therapy for Women Inc. in Wilmington, N.C. In addition, women with pre-existing medical conditions that limit activity, such as scoliosis and fibromyalgia, are more susceptible.

Most of Whaley's prenatal patients present with low back pain, sciatica symptoms or sacroiliac (SI) discomfort. She also sees patients with pelvic floor heaviness/pressure, pubic symphysis pain, significant urinary leakage and carpal tunnel syndrome.

Postpartum, patients are usually referred to Whaley a few weeks following delivery with complaints of dyspareunia (pain during intercourse), urinary leakage, persistent perineal pain due to an episiotomy or perineal tear during delivery, and low back or SI pain. Occasionally, she sees women who are experiencing blocked milk ducts or coccyx pain.

Although there are different issues for women who deliver vaginally versus Cesarean section, Whaley points out that many of these situations are caused by the pregnancy itself, not the method of delivery. As a result, she cautions women against requesting a C-section to avoid pelvic floor or perineal issues. C-sections carry their own set of risks, the least of which include abdominal adhesions and weakness, postural dysfunction and generalized low back pain.

Choice of pain management techniques during labor can also influence postpartum symptoms. For example, Yaron notices more back pain among women who receive an epidural during labor, compared with women who walk around and use various positions to allow gravity to open the pelvis for a vaginal delivery. And if a drug-free birth is planned but interrupted, the mother may experience a sense of disappointment or defeat, which can manifest in other syndromes, she says.

STRETCHING THE LIMITS

It's easy to ignore symptoms that don't cause severe pain or dysfunction. But as pregnancy progresses, mild discomforts can become monumental without intervention. If women seek help early, clinicians can provide education on proper posture and prescribe exercises to increase strength and flexibility, and alleviate discomfort. Women who wait until they're close to term usually have more acute pain, which reduces treatment to pain management.

Knowing how far along a woman is in her preganancy is important for other reasons, as well. The American College of Obstetrics and Gynecology suggests that women avoid the supine position after the first trimester to prevent possible maternal hypotension, which can decrease blood supply to the fetus.

"Clinicians working with pregnant clientele on a regular basis know the positional and exercise restrictions like they know the back of their hand," she says. However, clinicians new to the specialty have to realize exercises must be modified and that patients' tolerance and endurance levels are typically compromised. Watch for shortness of breath, a rapid heart rate, palpitations, dizziness or new pain. If any of these symptoms occur, try adjusting the position, modifying the exercise or stopping.

Before developing a plan of care, consider where the patient is in her pregnancy for hormonal fluctuations, Leise advises, and make sure she's not consuming excessive amounts of caffeine that can cause dehydration. Also ask about a woman's home and occupational requirements, number of previous pregnancies, number of children at home and weight gain during pregnancy. Postpartum, inquire about nursing history to understand possible hormonal fluctuations or imbalances that may contribute to joint laxity.

Once you complete a thorough patient history and assessment, you can delve into your patient's problem. While every woman's pregnancy is different, two of the most frequent problems include back pain and urinary incontinence.

• Back pain. Back pain is the most common physical complaint during pregnancy—it occurs approximately 50 percent of the time. And it's usually the most debilitating. Everyday activities become difficult with pregnancy alone, but the added pain becomes too much for some women to handle. As a result, women become less active, which often causes pain to worsen.

Whaley's first line of defense is educating patients about the musculoskeletal changes that occur during pregnancy. "By explaining the role of the abdominal, back and pelvic floor muscles, patients seem to understand the importance of a specific, consistent exercise program," she says. Whaley emphasizes stretching to maintain flexibility and practicing ideal posture at all times.

Exercise and manual therapy, soft tissue mobilization and myofascial release can also be effective. Whaley frequently employs large fitness balls and foam rollers, and provides patients with a prenatal body cushion, which lets them lie prone for manual treatments throughout pregnancy.

Yaron promotes the importance of upper back strengthening—even if she's treating low back pain. As the breasts get larger, women are more susceptible to forward head posture and rounded shoulders. Such postures stress and fatigue neck and back muscles, and can lead to trigger points that complicate the pain cycle. Strengthening these muscles facilitates scapular retraction. Yaron starts women with weights or resistance machines in early stages of pregnancy and then recommends fitness bands for home use.

Postural imbalance and sacroiliac joint (SIJ) dysfunction are also to blame for many cases of low back pain and sciatica during pregnancy. To see if misalignment is the culprit, Yaron conducts a full postural assessment of the pelvis, spine, shoulders and feet. In cases of muscular imbalance, she attempts to stretch and strengthen surrounding muscles and prescribes dynamic stabilization exercises.

For women whose symptoms continue or are severe, or whose work involves standing and lifting, Whaley and Leise consider recommending a prenatal abdominal support, or SI belt. Whaley has the most success and compliance with a device that features both an abdominal support and SI compression component. The components may be worn together or separately, depending on the patient's issues.

Managing back pain should include stretching the hip flexors and strengthening the core. Pregnancy stretches out the abdominal muscles, which pulls the pelvis forward to tighten the hip flexors. A lot of women work at desk jobs, which tends to make hip flexors even tighter. Strengthening the gluteal and transverse abdominal muscles can help keep the pelvis neutral, Yaron explains. The transversus abdominis is one of the most overlooked parts of the abdominal region. Since the muscle works with the pelvic floor and supports the body's center of gravity, Yaron makes it a treatment focus, regardless of a patient's primary issue.

• Incontinence. Incontinence can be an embarrassing and intrusive consequence of pregnancy and delivery. Helping women overcome this problem begins by educating them on pelvic floor anatomy, role and function. Then, most programs focus on strengthening the pelvic floor through therapeutic exercise, manual therapy and bowel/bladder retraining that's aided by electrical stimulation or biofeedback. Postpartum, internal techniques may be incorporated to facilitate progress.

Kegel exercises are also important for this patient population, says Heather Skaar, PT, manager of outpatient therapy at the Vanderbilt Orthopaedic Institute in Nashville, Tenn. When performed properly and consistently, these exercises can strengthen the pelvic floor and help relax the pelvic floor muscles for delivery.

To perform Kegel exercises, ensure that only the musculature of the pelvic floor is being contracted, Skaar explains. Advise patients to imagine they're urinating and that they need to stop the flow. Patients should visualize pulling up and in, and avoid bearing down or pushing out during the contraction to activate the pelvic floor musculature properly. Other compensatory techniques include engaging the abdominal, buttock, hip or thigh musculature during contraction.

Once patients achieve a proper pelvic floor contraction, then they can practice

several techniques.

1. Basic contraction: Contract the pelvic floor muscles, hold for 10 seconds and relax for 10 seconds. Perform 10 repetitions, 4 times a day.

2. Elevator: Slowly contract the pelvic floor musculature imagining you are going "up" on an elevator. As you come down, slowly release, level by level, until the pelvic floor muscles are completely relaxed. Repeat 10 times.

3. Flicker: Tighten and release the pelvic floor muscles quickly. Hold the contraction for 1 to 2 seconds and relax for 1 to 2 seconds. Perform 20 to 30 reps.

Patients who can't complete the optimal regimen can gradually work up to full duration. These exercises are gentle, and typically don't need to be modified during pregnancy, says Skaar. Women who have C-sections may be cleared to complete isometric abdominal exercises and Kegel exercises immediately postpartum and can usually progress to typical abdominal exercises after 4 to 6 weeks. However, Skaar recommends clearing all exercise programs with a physician, since pregnancies and deliveries present unique considerations depending on length of labor and method of delivery.

SUPPORTING EFFORT

Being a mother of one with another on the way has helped Leise understand the importance and limitations of rehabilitation during pregnancy and postpartum. "Not limitations of the therapy, but limitations of the patient," she explains.

For example, during her first pregnancy, Leise devoted all her attention to creating the ideal environment for her baby. But having a 2-year-old at home has shifted her priorities this time. Working out 5 times a week isn't feasible, and caring for a child during pregnancy entails postures and activities that are more taxing on her body.

The experience has taught her that treatment must account for all aspects of a patient's life. When a client reports difficulty completing a home exercise program, Leise sympathizes. As a result, she designs individual regimens that women can perform without a lot of equipment, time or set-up.

Educating clients on prevention strategies is equally important to help them avoid a recurrence of symptoms in subsequent pregnancies. Prior to pregnancy, women should attempt to achieve their ideal body weight, establish a regular cardiovascular workout program, and begin stretching and strengthening their abdominal and pelvic floor muscles. Reviewing basic ergonomics can also help busy moms avoid improper posture patterns that can incite or exacerbate another condition.

"I've noticed that we're getting more referrals for our Ôhealthy' pregnant population, with a desire to obtain an appropriate exercise program and gain education about their ideal fitness level throughout the various stages of pregnancy," notes Whaley.

This is good news. As women seek proactive measures to improve their pregnancies, there will be happier, healthier mothers in the future.

Jennifer Romanchick is associate editor of ADVANCE and can be reached at jromanchick@advanceweb.com

Applying biofeedback for incontinence

Biofeedback applications can help manage cases of incontinence. With biofeedback, electrodes are placed over the pelvic floor muscle to "read" muscle activity. A wire connects the electrode to a monitor to allow patients to watch muscle contractions. Patients can learn how much to squeeze, when to let go and how many exercises to do.

Two types of biofeedback can be beneficial: biofeedback via perineometer and biofeedback via sEMG. The perineometer serves as a device to make patients aware of the correct muscle contraction. The perineometer is also a pneumatic resistance device that measures contractions in millimeters of mercury, and centimeters or inches of water when inserted into the vagina. As the patient contracts the pubococcygeal muscle (located 1 to 2 inches inside the vagina), the meter reflects pressure change and provides objective information about contractions.

Electromyography (EMG) evaluates and records physiologic properties of muscles at rest and during contractions. EMG uses an electromyograph to detect the electrical potential generated by muscle cells at contraction, and when cells are at rest.

Surface electromyographic (sEMG) biofeedback measures electrical activity that leads to action. This electrical activity correlates to muscle fiber recruitment, which is an indirect measure of strength.

Tatum Wilson, PT, is on staff at the Texas Back Institute in Plano, Texas.