*1 Dance & Pe2


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  • PE is a serious and growing pregnancy disorder…defined as BP > 140/90 after 20 weeks with proteinurea….overt symptoms also include sudden swelling or edema of face and hands. U.S. has been around 4% annually, but is rising. Our community runs around 8% and has for some time. In developing world runs as high as 50%. Results in immune, CV and metabolic dysfunction that carries into later life for mother. Fetal programming = altered vascular responses, predisposition to CV disorders Sequellae often include pre-term birth (PTB <37 weeks) and low birth weight (LBW <5.5 lbs. or 3,000 gm.)
  • Normal pregnancy involves modulating cytokine and cytochemical responses directed by the interplay of the trophoblast - or invading fetal cells - and the maternal immune system. Trimester 1: pro-inflammatory responses permitting fertilization & adequate implantation Trimester 2: anti-inflammatory protection for mother and fetus Trimester 3: pro-inflammatory responses permitting an adequate rejection response to initiate labor and birth In a PE pregnancy, this pattern is blunted. Eventually, we would like to determine how this pattern is affected by physical activity.
  • What about evidence to date? Mostly epidemiological info. 1999 military study -- PA improved rates of PE in racially diverse population of pg soldiers 2003 PA & risk -- case controlled study demonstrating association of reduced risk of PE with maternal PA 2004 leisure activity -- associated with reduced rates of PE 2005 RPE -- level of perceived exertion in pre-pregnancy PA has inverse relationship to risk for PE 24 – 54 – 75% reductions The standardization and translational difficulties were areas we could bypass. So we were curious if we could duplicate these findings in some way.
  • So we set out to find out the PE rate might be of our dancing groups versus the larger population in our area, and how do these results compare with other findings.
  • Method: We examined hospital and public health records (FIMR) to determine outcomes for control groups. PE records available from care coordination records, but PTB & LBW only available through FIMR, thus smaller control. Experimental group - Compliance - had to begin the program prior to first modulation (16-24 weeks) and participate regularly until either gave birth or were removed from program for medical reasons. Reason for secondary measures of PTB & LBW - allow us to assess the “treatment” value of the program. Self-reporting subgroup information gathered from outcome records for the program, including attendance records and self-reporting of birth outcomes of participants…which tend to be very dependable. If you have given birth you will understand why! Questionnaires included questions such as were told you had a diagnosis of PE? Elevated BP? Proteinurea? Due date and baby’s birth date? Baby’s birth weight? For the High Risk assigned group information was maintained during the course of their pregnancies that enabled us to draw the information from our own files.
  • This study is part of a larger HIC approved experimental protocol underway on the immunology of healthy versus preeclamptic pregnancies. Epidemiological studies indicate aerobic activity may help prevent preeclampsia, but have not controlled for differences in amount, type, or intensity of activity. Laboratory-based interventions to control for variables inflict translational difficulties. To control for variables and bypass translational issues, we examined a standardized 30-year old community program.
  • Control - 781/ 9949 Experimental - 2/119
  • 300 women observed and randomized in a 1:1 fashion Estimate of the power of this study. If the observed number of PE cases is 20, for example, and if these are distributed as 5 in the physical activity and 15 in the control group then the two-tailed p-value of .041 rejects the null hypothesis of no benefit. If the benefit provides a 3:1 odds (that is cases are 3 times as likely to appear in the control group) then the probability (power) of detecting such a difference is 62%. The power increases with the numbers of PE cases observed and larger underlying odds ratios. More extreme observed imbalances of PE cases such as 4 / 16 would provide even further evidence of a benefit with a more extreme level of significance.
  • Control - 505/4053 Experimental - 6/119
  • Control - 450/4053 Experimental - 1/119
  • Top row: gestational age Bottom row: birth weight Self-selecting mothers on Left High-risk, assigned mothers on Right
  • *1 Dance & Pe2

    1. 1. Effect of a community dance program on the rate of preeclampsia in pregnancy Ann Cowlin, MA , Yale University Department of Athletics, New Haven, Connecticut, USA; Robyn Brancato Ovozek, CNM, MA ; Brookdale Hospital, Brooklyn, New York, USA; Gil Mor, MD, PhD ; Daniel Zelterman, PhD; Brian Karsif, MD, MPH, Yale University School of Medicine, New Haven, Connecticut, USA; Peggy DeZinno, RN, BSN , Yale-New Haven Hospital, New Haven, Connecticut, USA.
    2. 2. Effect of Prenatal Dance on PE Risk <ul><li>Background </li></ul><ul><ul><li>Preeclampsia (PE) described: </li></ul></ul><ul><ul><ul><li>Complex disorder of pregnancy & downstream CVD </li></ul></ul></ul><ul><ul><ul><li>BP > 140/90 after 20 weeks, with proteinuria </li></ul></ul></ul><ul><ul><ul><li>Characterized by endothelial dysfunction, affecting the placenta </li></ul></ul></ul><ul><ul><ul><li>Causes include infection and metabolic disorder of pregnancy, affecting placental function </li></ul></ul></ul><ul><ul><ul><li>Genetic predisposition </li></ul></ul></ul><ul><ul><ul><li>Immune, cardiovascular & metabolic dysfunction </li></ul></ul></ul><ul><ul><ul><li>Responsible for 15-40% of preterm birth (PTB: <37 weeks), low birth weight (LBW: <5.5 lbs) and - likely - adverse fetal programming (e.g. autism, CVD) </li></ul></ul></ul>
    3. 3. Effect of Prenatal Dance on PE Risk <ul><li>Background </li></ul><ul><li>From Mor, G., Trophoblast as Immune Regulators in Immunology of Pregnancy, Chapter 19, 2006 </li></ul>
    4. 4. Effect of Prenatal Dance on PE Risk <ul><li>Background </li></ul><ul><ul><li>Evidence for a beneficial effect of PA </li></ul></ul><ul><ul><ul><li>Lombardi, 1999 (military study) </li></ul></ul></ul><ul><ul><ul><li>Sorenson, 2003 (PA & risk of PE) </li></ul></ul></ul><ul><ul><ul><li>Saftlas, 2004 (leisure activity) </li></ul></ul></ul><ul><ul><ul><li>Rudra, 2005 (RPE & prepregnancy PA) </li></ul></ul></ul><ul><ul><li>Methods: largely recall of varying modalities </li></ul></ul><ul><ul><li>Difficulties </li></ul></ul><ul><ul><ul><li>Standardization </li></ul></ul></ul><ul><ul><ul><li>Translation for public health enhancement </li></ul></ul></ul>
    5. 5. Effect of Prenatal Dance on PE Risk <ul><li>Purpose of This Project </li></ul><ul><ul><li>To determine rates of 1) PE, and 2) PTB & LBW, in a community prenatal dance program versus the larger pregnant community. </li></ul></ul><ul><li>Secondary Purpose </li></ul><ul><ul><li>To determine if a community prenatal dance program that is standardized, quality controlled, and culturally sensitive can reproduce the finding of reduced risk for PE consistent with other exercise studies. </li></ul></ul>
    6. 6. Effect of Prenatal Dance on PE Risk <ul><li>Method </li></ul><ul><ul><li>Retrospective </li></ul></ul><ul><ul><li>Control Group </li></ul></ul><ul><ul><ul><li>PE Control Group: 9,949 women delivering at a major U.S. teaching hospital in 2004-2005 </li></ul></ul></ul><ul><ul><ul><li>PTB & LBW Control Group: 4,053 subset of community residents who delivered at the hospital 2004-2005 </li></ul></ul></ul><ul><ul><li>Experimental Group 119 women… </li></ul></ul><ul><ul><ul><li>Self-selecting Subgroup: 88 program compliant women </li></ul></ul></ul><ul><ul><ul><li>High-risk, assigned Subgroup: 31 women in a controlled environment </li></ul></ul></ul><ul><ul><li>Outcome Measures </li></ul></ul><ul><ul><ul><li>PE </li></ul></ul></ul><ul><ul><ul><li>PTB & LBW </li></ul></ul></ul>
    7. 7. Effect of Prenatal Dance on PE Risk <ul><li>Design </li></ul><ul><ul><li>Community-Based Prenatal Dance program </li></ul></ul><ul><ul><ul><li>Standardized, proprietary program </li></ul></ul></ul><ul><ul><ul><li>In existence for 30 years </li></ul></ul></ul><ul><ul><ul><li>Excellent compliance record among diverse groups </li></ul></ul></ul><ul><ul><ul><li>Able to easily track progress and compliance </li></ul></ul></ul><ul><ul><ul><li>Allows us to account for group support </li></ul></ul></ul><ul><ul><ul><li>Reduces standardization & translational issues </li></ul></ul></ul>
    8. 8. Effect of Prenatal Dance on PE Risk <ul><li>Design </li></ul><ul><ul><li>Program Components </li></ul></ul><ul><ul><ul><li>Centering floorwork (neutral posture, slow breathing, TrA activation) </li></ul></ul></ul><ul><ul><ul><li>Graham/Hawkins, Feldenkrais, Alexander, Ideokinesis, Belly Dance, Pilates & Yoga </li></ul></ul></ul><ul><ul><ul><li>Relaxation Response (as per Benson) </li></ul></ul></ul><ul><ul><ul><li>Strength work based on needs of prenatal posture </li></ul></ul></ul><ul><ul><ul><li>Special birth preparation exercises </li></ul></ul></ul><ul><ul><ul><li>Aerobic Dancing 20-30 minutes 2 X/week </li></ul></ul></ul><ul><ul><ul><li>Opportunity for socialization and support </li></ul></ul></ul>
    9. 9. Effect of Prenatal Dance on PE Risk NOTES: • In Dance group, 5 cases of elevated BP and 4 cases of proteinuria >20 weeks, not progressing to PE. • Both cases of PE diagnosed in final month.
    10. 10. Effect of Prenatal Dance on PE Risk <ul><li>Power Table </li></ul>.97 .89 .80 .70 .62 4:1 odds .87 .73 .62 .52 .46 3:1 odds .53 .37 .30 .26 .23 2:1 odds Power against: .071 .043 .041 .057 .065 2-tail p-value 10/21 7/18 5/15 3/11 2/9 Critical value 31 25 20 14 11 Number of pre-eclampsia cases
    11. 11. Effect of Prenatal Dance on PE Risk Notes: 6 PTB infants, none with LBW or belonging to PE mothers.
    12. 12. Effect of Prenatal Dance on PE Risk
    13. 13. Effect of Prenatal Dance on PE Risk
    14. 14. Effect of Prenatal Dance on PE Risk <ul><li>Conclusions </li></ul><ul><ul><li>Findings support the hypothesis that a standardized community-based prenatal dance program results in low rates of 1) PE and 2) PTB & LBW. </li></ul></ul><ul><ul><li>Participating in such a program may help dance professionals, serious amateurs, and general population participants remain healthy in this critical period, thereby promoting long-term health. </li></ul></ul>
    15. 15. Effect of Prenatal Dance on PE Risk <ul><li>The “Take-Home” Messages </li></ul><ul><ul><li>There may be an ideal physical activity form for a healthy pregnancy, birth and recovery: Group Dance with intentional choreography that maximizes benefits. </li></ul></ul><ul><ul><li>Efficacious Prenatal Dance forms are untapped resources for our discipline…both as a benefit for our artists and as a way to engage the public in meaningful dance experiences within the community. </li></ul></ul>
    16. 16. Our research team <ul><li>        </li></ul>Ann Cowlin, MA , Yale University Department of Athletics, New Haven, Connecticut, USA. Movement Specialist. Consultant, School of Medicine. <ann.cowlin@womenshealthfitness.org> Robyn Brancato Ovozek, CNM, MA ; Obstetrics, Brookdale Hospital, Brooklyn, New York, USA. Certified Nurse Midwife. Gil Mor, MD, PhD, Yale University School of Medicine, New Haven, Connecticut, USA. Director, Reproductive Immunology Unit, Department of Obstetrics, Gynecology and Reproductive Sciences. Daniel Zelterman, PhD, Yale University School of Medicine, New Haven, Connecticut, USA. Professor of Biostatistics, Department of Epidemiology and Public Health. Brian Karsif, MD, MPH, Yale University School of Medicine, New Haven, Connecticut, USA. Assistant Clinical Professor, Department of Obstetrics, Gynecology and Reproductive Sciences. Coordinator, Maternal/Child Health, Connecticut State Medical Society and Dept. of Public Health. Peggy DeZinno, RN, BSN , Yale-New Haven Hospital, New Haven, Connecticut, USA. Coordinator, WELL/A Mother’s Place at YNHH.
    17. 17. Thank you for your attention. <ul><li>References 1 </li></ul><ul><li>1. Clapp, JF 3rd. (2002). Exercising Through Your Pregnancy . Addicus Books. </li></ul><ul><li>2. Dempsey, J. C., Butler, C. L., Sorensen, T. K., Lee, I. M., Thompson, M. L., & Miller, R. S. et al. (2004). A case-control study of maternal recreational physical activity and risk of gestational diabetes mellitus. Diabetes Research and Clinical Practice, 66 (2), 203-215. </li></ul><ul><li>3. Enquobahrie, D. A., Williams, M. A., Butler, C. L., Frederick, I. O., Miller, R. S., & Luthy, D. A. (2004). Maternal plasma lipid concentrations in early pregnancy and risk of preeclampsia. American Journal of Hypertension : Journal of the American Society of Hypertension, 17 (7), 574-581. </li></ul><ul><li>4. Ning, Y., Williams, M. A., Butler, C. L., Muy-Rivera, M., Frederick, I. O., & Sorensen, T. K. (2005). Maternal recreational physical activity is associated with plasma leptin concentrations in early pregnancy. Human Reproduction (Oxford, England), 20 (2), 382-389. </li></ul><ul><li>5. Dempsey, J. C., Butler, C. L., & Williams, M. A. (2005). No need for a pregnant pause: Physical activity may reduce the occurrence of gestational diabetes mellitus & preeclampsia. Exercise and Sport Sciences Reviews, 33 (3), 141-149. </li></ul><ul><li>6. Saftlas, A. F., Logsden-Sackett, N., Wang, W., Woolson, R., & Bracken, M. B. (2004). Work, leisure-time physical activity, and risk of preeclampsia and gestational hypertension. American Journal of Epidemiology, 160 (8), 758-765. </li></ul><ul><li>7. Lombardi, W., Wilson, S., & Peniston, P. B. (1999). Wellness intervention with pregnant soldiers. Military Medicine, 164 (1), 22-29. </li></ul><ul><li>8. Rudra CB, Williams MA, Lee IM, Miller RS, Sorensen TK.(2005). Perceived exertion during prepregnancy physical activity and preeclampsia risk. Medicine & Science in Sports & Exercise , 37 (11), 1836-41. </li></ul><ul><li>9. Mor, G. (2006). Trophoblast as Immune Regulator, Immunology of Pregnancy , ch. 19. </li></ul><ul><li>10. Parnell, M. M., Holst, D. P., & Kaye, D. M. (2005). Augmentation of endothelial function following exercise training is associated with increased L-arginine transport in human heart failure. Clinical Science 109 (6), 523-530. </li></ul>
    18. 18. Thank you for your attention. <ul><li>References 2 </li></ul><ul><li>11. Rush, J. W., Denniss, S. G., & Graham, D. A. (2005). Vascular nitric oxide and oxidative stress: Determinants of endothelial adaptations to cardiovascular disease and to physical activity. Canadian Journal of Applied Physiology 30 (4), 442-474. </li></ul><ul><li>12. DeSouza, C. A., Shapiro, L. F., Clevenger, C. M., Dinenno, F. A., Monahan, K. D., & Tanaka, H. et al. (2000). Regular aerobic exercise prevents and restores age-related declines in endothelium-dependent vasodilation in healthy men. Circulation, 102 (12), 1351-1357. </li></ul><ul><li>13. Febbraio, M. A., & Pedersen, B. K. (2005). Contraction-induced myokine production and release: Is skeletal muscle an endocrine organ? Exercise and Sport Sciences Reviews, 33 (3), 114-119. </li></ul><ul><li>14. Petersen, A. M., & Pedersen, B. K. (2005). The anti-inflammatory effect of exercise. Journal of Applied Physiology: Respiratory, Environmental and Exercise Physiology, 98 (4), 1154-1162. </li></ul><ul><li>15. Clapp JF III and Kiess W. (2000). Effects of pregnancy and exercise on concentrations of the metabolic markers tumor necrosis factor alpha and leptin . American Journal of Obstetrics and Gynecology 182(2):300-306. </li></ul><ul><li>16. Ischlander M, Zaldivar Jr. F, Eliakim A, Nussbaum E, Dunton G, Leu S, Cooper DM and Schneider, M. (2007). Physical activity, growth and inflammatory mediators in BMI-matched female adolescents, Medicine and Science in Sports and Exercise 39(7):1131-1138. </li></ul><ul><li>17. Cowlin, A. F. (2002). Women's Fitness Program Development . Champaign, Il: Human Kinetics. </li></ul><ul><li>18. Costanzo ES, Lutgendorf SK, Sood AK, Anderson B, Sorosky J and Lubaroff DM. (2005). Psychosocial factors and interleukin-6 among women with advanced ovarian cancer, Cancer 104(2):305-313. </li></ul><ul><li>19. Hart, M. A. (1993). Self-care agency and prenatal care actions: Relationships to pregnancy outcomes . Unpublished dissertation, Case Western Reserve University, Cleveland, OH. </li></ul>