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Ex in post natal period
1. The document provides information on exercise prescription in the post-natal period, including detailing the post-partum phases, common musculoskeletal and neurological impairments, and appropriate physical therapy interventions. 2. Recommendations include encouraging early mobility to reduce risks, pelvic floor muscle exercises for pain relief and strengthening, and stabilization exercises progressed cautiously based on impairments. Modalities like ice, ultrasound, and electrical stimulation may assist with pain and dysfunction. 3. Physical therapy can effectively treat common post-natal issues like low back pain, pelvic girdle pain, and urinary incontinence when appropriate exercises and modalities are implemented safely based on each woman's individual presentation.
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Ex in post natal period
- 1. Exercise prescription in Post-natalperiod -Ms Lenita Moderator- Ms Sidhi Mohopatra
- 3. • Post- afterNatalis- birth • The period beginning immediately after the birth of a child and extending for about six weeks. • The average hospital stay for spontaneous vaginal delivery (SVD) is 1–2 days, and the average caesarean section postnatal stay is 3–4 days. • The mother is monitored for bleeding, bowel and bladder function, and baby care.
- 4. Post-partum phases • (Postpartumperiod: three distinct but continuous phases. Journal of Prenatal Medicine 2010; 4 (2): 22-25. Mattea Romano, Alessandra Cacciatore , Rosalba Giordano and peatrice La Rosa.)
- 5. Phase Duration Mainfeatures Phase 1 (acute phase) 6-12 hours Period of crisis Phase 2 (sub-acute) 2-6 weeks Major changes Phase 3 (delayed post- partum) Up to 6 months Residual complications
- 7. Musculoskeletal Neurological Laxity ofligaments and muscles Nerve traction injuries Diastasis Nerve plexus injuries Decreased mechanical control of abdominal corset Compression syndromes Weakened pelvic floor muscles Bladder/ bowel dysfunction Back pain Analgesia induced sensory and motor deficit
- 8. Musculo skeletal adaptations •Anatomical and physiological changes during pregnancy have the potential to affect the musculoskeletal system at rest and during exercise. • The most obvious of these is weight gain. • The increased weight in pregnancy may significantly increase the forces across joints such as the hips and knees by as much as 100% during weight bearing exercise such as running. • Such large forces may cause discomfort to normal joints and increase damage to arthritic or previously unstable joints. • Because of anatomical changes, pregnant women typically develop lumbar lordosis, which contributes to the very high prevalence (50%) of low back pain in pregnant women. • Balance may be affected by changes in posture, predisposing pregnant women to loss of balance and increased risk of falling
- 9. • Numbness ofthe perineum in the first few hours. • Pain caused by labial tears, episiotomy, oedema and haematoma. • PFM contractures. • Increased urine output. • Urgency, pain on micturation, stress incontinence, retention of urine and occasionally faecal incontinence. • Women who have had an epidural may have impaired bladder sensation. Genito-urinary
- 10. Vascular Psychological edema Postpartumdepression Varicose veins Baby blues DVT Baby pinks Pulmonary embolism thrombophlebitis
- 11. Impairments Tool Pain VAS Pelvicfloor weakness digital examination Abdominal muscle weakness Palpation Urinary incontinence Pad method, voiding diary. Fatigue Brief fatigue inventory Impaired bladder sensation/ volition Bowel/ bladder exam Diastasis Palpation Compression injuries Sensory, motor exam, NCV Activity Limitation Impaired bed mobility Difficulty in moving out of bed and ambulation Discomfort while laughing or sneezing ADL dependence
- 12. Thomson`s et al(2002) study proposed (n=1295) that: - - Primiparas= were most likely to report perineal pain and sexual problems. -Caesearean births (when compared to unassisted vaginal deliveries) .Were most likely to suffer exhaustion and bowel problems.Reported less perineal pain and urinary incontinence .Were most likely to be readmitted. -Forceps delivery (when compared to unassisted vaginal deliveries) Reported more perineal pain
- 13. Symptoms to lookout for / consider referral on include: - Diastasis rectii abdominis- Inability to voluntary contract the pelvic floor - Perineal pain or discomfort - Symphysis pubis pain or referred pain - Back pain or discomfort
- 17. • Mother shouldbe encouraged to be mobile and thereby reduce the risk of circulatory and respiratory dysfunction • If confined to bed for prolonged period of time- controlled and deep breathing exercise and vigorous circulatory exercises should be encouraged • Pelvic floor muscle exs- for strengthening and pain relieving properties. • Finding the right starting position for the exercise will be the key to effectiveness.
- 18. essential point- •Contract thepelvic floor muscles every time the intra-abdominal pressure increases •A more efficient contraction may be obtained by contracting the transverse abdominus, before engaging the pelvic floor muscles.
- 19. Type Mode IntensityFrequency Duration Progression Aerobic walking, aerobic dance, swimming, cycling. Moderate 3- 4 METS. 50- 60% VO2 max. RPE: 12-16 30 minutes per day most days of the week. 20-60 minutes as per patient tolerance. Increase exercise duration slowly. Flexibility Aquatic exercise ROM ex’s full mobility Strength Light weights/incre ased reps. 12 reps, individually tailored with monitoring. Precautions: supine position, increased joint compression.
- 20. Procedure indications Precautions “Squeezeand lift” Slow and fast contractions 3 sets of 8-12 contractions. Urinary incontinence Faecal “ Bladder/urethr al prolapse Nerve injuries Hypertensive patients. Full bladder Prevent breath hold
- 21. Stage Procedure PrecautionsProgression Stage 1 The deep abdominals breathing control Prone, side-lying and quadruped. 5-10 reps. 10 second holds 10 times Stage 2 the pelvic tilt. Avoid tightly flattening abdomen. Stage 3 the head lift Avoid sit-up, twisting Progress to shoulder lift
- 22. • ABSOLUTE CONTRAINDICATIONSTO EXERCISE (ACOG) • Haemodynamically significant heart disease • Restrictive lung disease • Functional weakness of cervix • Premature labour during the current pregnancy • Ruptured membranes • REALTIVE CONTAINDICATIONS (ACOG) • Severe anaemia • Unevaluated maternal cardiac arrhythmia • Chronic bronchitis • Poorly controlled type I diabetes • Extreme morbid obesity • Extreme underweight (body mass index <12) • History of extremely sedentary lifestyle • Poorly controlled hypertension • Orthopaedic limitations • Poorly controlled seizure disorder • Poorly controlled thyroid disease
- 24. • Head shouldbe in line with the trunk • Maintain natural curves of the spine • Avoid hyperextension • Avoid in toeing • Asymmetrical weight • Shoulders relaxed and arms held loosely at the side
- 25. • Fully supportedwith pillows. • Uncross legs • Avoid sustained isometric trunk flexion, rotation. • Keep movement within sagittal plane • Perform activities at an appropriate height
- 26. • Kneel Sitting: •Bilateral • Half kneel sitting: • Unilateral-sitting on one Heel,other hip forward flexed With foot flat on the floor
- 27. • Nappy changing- -Nappychanging is a another activity that can result in pain -Positions that increase the risk to the mother should be avoided for eg sitting with knees extended and trunk flexed -erogonomic positions should be explained to the mother -suggested positions for nappy changing could be sitting standing and kneeling
- 28. • Meditation • Mentalimagery • Deep breathing • Yoga • Jacobsson’s Technique • Progressive relaxation technique
- 29. Musculoske letal Genitourina ry Neurogenic psychologic al Circulatory Conditions Diastasis Recti Backpain Coccdynia Symphysis pubis pain After pains Stress incontinencef aecal incontinence Perineal tears Lacerations Genital prolapse Plexus injuries Compression syndromes Postpartum depression Maternity blues Puerperal psychoses PND Varicose veins Edema Superficial vein thrombosis DVT Pulmonary embolism Treatment Thermal/cold modalities, Mob, Relaxation, muscle re- education PF ex’s, timed voiding techniques, catherterizati on. NMES, muscle re- education, Hospitalizati on, anti- psychotic drugs, counseling. Stockings, elevation, ATM’s, general ex’s.
- 30. Perineal pain • Pelvicfloor muscle exs- - repeated voluntary contraction and relation will relieve the pain..............repeated pumping action assist venous and lymphatic drainage and the removal of traumatic exudates, thus relieving stiffness and restoring function. • Ice ( moore & james 1989) compared 3 topical agents with cold therapy in the treatment of post episotomy position. Ice gave better pain relief • Crushed ice wrapped in a damp disposable gauze or a disposable wash cloth and applied to the affected are for 5-10mins (plastic acts as an insulator therefore effectiveness is reduced) • Ice cube massage-an ice cube held in a tissue and used by the woman herself while on the bed or sitting in the toilet can give excellent pain relief
- 31. • Ultrasound – •To increase temp, in turn increases blood flow and increases repair. Twice daily and does not interfere with functional acivities - Treatment is best in crooked lying or sidelying position (for better visualisation of area) - Ultrasound head is then appled through a coupling gel medium, and in accordance with local infection guidelines - Pulsed ultrasound is used for analgesic and exudates removing properties - Initial treatment- 3MHz, 0.5W/cm, and 2mins per head sized area was used.
- 32. • Effectiveness ofphysical therapy for pregnancy- related low back and/or pelvic pain after delivery: A systematic review. 2012. (1) • Pain showed consistent decrease. • Stabilization ex’s performed under supervision showed better results. • The Efficacy of a Treatment Program Focusing on Specific Stabilizing Exercises for Pelvic Girdle Pain After Pregnancy A Randomized Controlled Trial. (2) 2004. • Significant improvements in pain, QOL and function compared to placebo.
- 33. •Stabilization exercises inpostnatal low back pain. 2011. --The second group showed statistically significant differences in pain reduction. An alternative intervention for urinary incontinence: Retraining diaphragmatic, deep abdominal and pelvic floor muscle coordinated function. 2010 Improved self reported symptoms Improved quality of life Decreased leakage No change in PFM strength
- 35. • A comparisonof high- versus low-intensity, high- frequency transcutaneous electric nerve stimulation for painful postpartum uterine contractions. 2007 • Women treated with HI TENS experiences lesser pain and discomfort than LOW TENS. • However discomfort of stimulation was higher in HI TENS group. • Transcutaneous Electrical Nerve Stimulation After Caesarean birth. 2007. • Decreased pain • Parameters used: carbon electrodes, frequency: 100 pps and pulse duration: 140-170 msec.
- 36. • Effect ofbehavioural training with and without pelvic floor electrical stimulation on stress incontinence in women. 2003. • No significant improvement in NMES group in terms of decreased leakage. • Parameters: Frequency: 20 Hz, Current: biphasic, pulse width: 1 millisec, duty cycle: 1:1 and intensity: 0-100 mA.
- 37. • Therapeutic ultrasoundfor postpartum perineal pain and dyspareunia. Cochrane review. 2009 • Decreases in acute pain and edema • Increased bruising at 10 days • Decreased long term discomfort.
- 38. • A randomisedcontrolled trial to compare the effectiveness of icepacks and Epifoamwith cooling maternity gel pads at alleviating postnatal perineal trauma. 2000. • Ice packs showed greater beneficial effect on pain, bruising and oedema. • Comparison of application times for ice packs used to relieve perineal pain after normal birth: a randomised clinical trial. 2007. • 10, 15 and 20 minutes application showed no significant differences in pain.
- 39. • Adverse eventsfrom spinal manipulation in the pregnant and postpartum periods: a critical review of the literature. 2012. • SMT could be performed safely in post-partum women with precautions.
- 40.
- 41. • 5-10 repsof each exercise. • Bridging Progression: weight shifts Progression: single leg bridge
- 42.
- 47. • 1. FerreiraCWS, Alburquerque-Sendn F. Effectiveness of physical therapy for pregnancy-related low back and/or pelvic pain after delivery: A systematic Review. Physiotherapy Theory and Practice, 2012; 1-3. (published online). • 2. Stuge B, Lærum E , Kirkesola G, Vøllestad P. The Efficacy of a Treatment Program Focusing on Specific Stabilizing Exercises for Pelvic Girdle Pain After Pregnancy A Randomized Controlled Trial. SPINE Volume 29, Number 4, pp 351–359, 2004. • 3. Vairajothi K, Chitra TV, Baranitharan R, Mahalakshmi V. A comparative study of the therapeutic effect of pelvic floor exercises and perineometer among women with urinary stress Incontinence. IJOPT, 2005, volume 5; number 1, pg 33-36. • 4. Amar TA. Stabilization exercises in postnatal low back pain. Indian Journal of Physiotherapy and Occupational Therapy. 2011, Vol. 5, No.1.
- 48. • 5. Hsiu-ChuanHung et al. An alternative intervention for urinary incontinence: Retraining diaphragmatic, deep abdominal and pelvic floor muscle coordinated function. Manual Therapy 15 (2010) 273–279. • 6. A randomised controlled trial to compare the effectiveness of icepacks and Epifoamwith cooling maternity gel pads at alleviating postnatal perineal trauma. Midwifery, 2000; 16, 48-55. • Hay-Smith J. Therapeutic ultrasound for postpartum perineal pain and dyspareunia. Cochrane Database of Systematic Reviews 1998, Issue 3. • 7. Doumulin C et al. Pelvic floor rehabilitation , Part II: Pelvic floor re-education with interferential currents and Exercise in the Treatment of Genuine Stress Incontinence in Postpartum Women --A Cohort study. PHYS THER. 1995; 75:1075-1081. • 8. Goode PS et al. Effect of behavioural training with and without pelvic floor electrical stimulation on stress incontinence in women. 2003. JAMA 2003- vol 290, no 3.
- 49. 9. Stuber KJ,Wynd S, Weis CA. Adverse events from spinal manipulation in the pregnant and postpartum periods: a critical review of the literature. Chiropractic & Manual Therapies 2012, 20:8 10. Sonia MJV Oliveira et al. Comparison of application times for ice packs used to relieve perineal pain after normal birth: a randomised clinical trial. PHYS THER. 1995; 75:1075-1081. 11. Hay-Smith J. Therapeutic ultrasound for postpartum perineal pain and dyspareunia (Review). 2009 The Cochrane Collaboration. • Textbook of obstetrics and Gynaecology Jill Mantle. • Jeffcoate’s principles of obstetrics and Gynaecology.