- Puerperium refers to the 6-week period following delivery where the body returns to its pre-pregnant state. This involves involution of the uterus, breasts, and other organs as well as hormonal and physiological changes. - Common issues during this period include uterine and breast involution, lochia, urinary changes, weight loss, endocrine changes, and psychological adjustment. Complications can include postpartum hemorrhage, infection, retained placenta, and painful perineum. Physical therapy modalities like cryotherapy, TENS, LLLT, and pelvic floor exercises can help manage pain.

4. -Puerperium is defined as the time from the delivery of the
placenta through the first few weeks after the delivery. This
period is usually considered to be 6 weeks in duration.
-By 6 weeks after delivery, most of the body tissue changes
of pregnancy, labor, and delivery, especially the pelvic organs
revert back approximately to the prepregnant state both
anatomically and physiologically.
-Similar changes occur following abortion but takes a shorter
period for the involution to complete.
-Fourth trimester is the time from delivery until complete physiological involution and
psychological adjustment.

5. Uterine involution:
Is the process by which the postpartum uterus, weighing about
1kg, returns to its pre pregnancy state of 50-100g.
1- Immediately after delivery: The uterine fundus is palpable
at or near the level of the maternal umbilicus. The measurement
should be taken after emptying the bladder.
2- 2 weeks after birth: the uterus becomes a pelvic organ in the
true pelvis.
3- By 6 weeks: it is usually normal size.
-Lower uterine segment: Immediately following delivery, the lower segment becomes a
thin, flabby and collapsed structure. It takes a few weeks to revert back to the normal
shape and size of the isthmus.

6. Endometrium:
-Following delivery, the major part of the decidua is cast off with the expulsion of the
placenta and the membranes, more at the placental site. The superficial part containing the
degenerated decidua, blood cells and bits of fetal membranes becomes necrotic and is cast off
in the lochia.
-Regeneration starts by 7th day. It occurs from the epithelium of the uterine glands and
stromal cells. Regeneration of the epithelium is completed by 10th day and the entire
endometrium is restored by the day 16, except at placental site where it takes about 6 weeks.
Placenta bed:
-The placental site contracts rapidly presenting a raised surface which measures
about 7.5 cm and remains elevated even at 6 weeks when it measures about 1.5 cm.

7. Myometrium:
-There is marked hypertrophy and hyperplasia of muscle fibers
during pregnancy and the individual muscle fiber enlarges to the
extent of 10 times in length and 5 times in breadth.
-During puerperium, the number of muscle fibers is not decreased,
but there is substantial reduction of the myometrial cell size.
Withdrawal of the steroid hormones, estrogen and progesterone, may
lead to increase in the activity of the uterine collagenase and release of proteolytic enzymes.
-The connective tissues also undergo the same type of degeneration.
The cervix:
-It involutes along with the uterine body but it contracts slowly, so
that by 2 to 3 weeks, the internal os is closed, while the external os
can remain open permanently, giving a characteristic appearance to the parous cervix.

8. The vagina:
-The Vagina gradually diminishes in size.
-In the 1st few days, the stretched vagina is smooth & edematous.
-By the 3rd week, vaginal rugae begin to reappear but never to the same
degree as in prepregnant state.
Broad ligaments and round ligaments:
-They require considerable time to recover from the stretching and laxation.
Pelvic floor and pelvic fascia:
-Take a long time may last to 6 months to involute from the stretching
effect during parturition.

9. Lochia:
-It Is the blood-stained uterine discharge that is consists of blood & necrotic decidua;
While persistence of red lochia means subinvolution, offensive lochia means infection.
Types of lochia:
1. Lochia rubra: for the first 4 days, lochia is red in
color. It contains blood as well as decidual debris.
2. Lochia serosa: from 5th to 9th day, lochia becomes
pale in color. It contains still some red cells, but
predominantly leucocytes and necrotic decidua.
3. Lochia Alba: after the 10th day, the lochia changes to yellowish
white color. It consists now principally of serous fluid and leucocytes.

10. Ovaries:
-The resumption of normal function by the ovaries is highly variable and is greatly
influenced by breastfeeding the infant. The woman who breastfeeds her infant has a longer
period of amenorrhea and anovulation than the mother who chooses to use formula.
-The onset of the first menstrual period following delivery is very variable and depends on
lactation. If woman does not breastfeed her baby, ovulation may occur as early as 4 weeks
postpartum while menstruation returns by 12th week following delivery in 80% of cases. The
meantime for onset of first menstruation is 6 – 9 weeks.
-Lactation provides a natural method of contraception whoever, in women who is
fully lactating, ovulation and menstruation may occur up to 6 -12 months.
-The physiological basis of anovulation and amenorrhea is due to elevated levels of prolactin
and oxytocin in response to baby’s suckling.

12. Breast tissue changes:
-Although lactation starts following delivery, the
preparation for effective lactation starts during pregnancy.
-Prolactin and Oxytocin initiate milk secretion from
mammary glands previously primed by estrogen and
progesterone.
-For the first 2 days there is secretion of colostrum which
a deep yellow serous fluid rich in protein, Lactoferrin
and immunoglobulin while low in its fat and
carbohydrates content.
-Proper milk secretion commences at the 3rd day and
it may be associated with breast engorgement.

13. COMPOSITION OF THE COLOSTRUM:
-It is deep yellow serous fluid, alkaline in reaction. It has got a higher specific gravity; a
high protein, vitamin A, sodium and chloride content but has got low carbohydrate, fat
and potassium.
-Colostrum and milk contains immunologic components such as immunoglobulins
(IgA, IgG, IgM), complements, macrophages, lymphocytes, lactoferrin and other enzymes.

14. Abdominal wall:
-The abdominal wall remains soft and poorly toned for many weeks.
The return to a pre pregnant state depends greatly on maternal exercise.
Physiologic changes:
-General Changes:
*Temperature → normal but,
-A reactionary rise may occur after difficult labor. It does not exceed 38°C and
drops within 24 hours.
-A slight rise may occur at the 3rd day due to engorgement of the breast tissue.
*Pulse → normal but may rise if there is hemorrhage or infection.
*After pains → Painful uterine contractions occur in early puerperium
increasing with suckling due to oxytocin release.

15. Urine Changes:
*Diuresis by the 2nd - 4th day, as normal pregnancy is associated with an increase in
extracellular water and puerperal diuresis is a reversal of this process.
*Retention of urine may occur due to:
-Atony of the bladder. -Laxity of the abdomen.
-Recumbency. -Reflex inhibition if the perineum is sutured.
-Compression of the urethra by vaginal edema.
So, there is an increased incidence of urinary tract infection.
Bowel Changes:
*Tendency to constipation due to;
-Atony of the intestine. -Laxity of abdomen and perineum.
-Anorexia. -Loss of fluids.

16. Loss of weight:
May be due to:
*Evacuation of the uterine contents (5–6 kg).
*More fluid loss in urine and sweat (2 kg).
Blood Changes:
*Immediately following delivery, there is slight decrease of blood
volume due to blood loss and dehydration.
*Increased coagulability of the blood continues during the first two
weeks despite significant decrease in several coagulation factors.
*Fibrinogen level remains high up to the 2nd week of puerperium
which increases the risk for thrombosis.
*Hemoglobin concentration tends to fall in the first 2-3 days.

17. Endocrinal changes:
*Sharp decrease in both estrogen and progesterone with rise in prolactin is the main
initiative for lactation.
*Baby’s Suckling induced signals stimulate oxytocin release which is a milk letting factor.
*There is slight increase in Growth hormone level also, cortisol and thyroxine and they
play role in lactation.
*Prolactin inhibit GNRH which result in lactational amenorrhea.
Psychological changes:
*Postpartum depression (mild degree) is common.

18. Postpartum care
*The postpartum care (PPC) is an extension of both antenatal care (ANC)
Provided during pregnancy and intrapartum care (IPC) provided during
delivery.
1-General health care: as physical and mental relaxation & reassurance.
2-Observation: for fever, bleeding and lochia.
3-Balanced diet: Providing at least 2500 kcal and diet rich in fibers.
4-Breast feeding: encourage breast feeding every 2-3 hours and encourage
the mother to take additional amounts of water & fresh juices.

19. 6-Perineal care: regular cleaning with antiseptic solutions to prevent Genital tract infections
and Pelvic floor exercise is started in the 3rd day if there is no perineal wound.
7-Care of episiotomy: Regular cleaning with antiseptic solution every 4-6 hours with the use
of LLLT to assist in healing and provide bactericidal effect for the incision.
8-Bowel care: avoid constipation by drinking sufficient amounts of water, eating food rich in
fibers and walking.
9-Bladder care: frequent emptying of bladder until it regains its pre pregnant tone and capacity.
10-Postpartum visits: the patient is best seen 3-4 weeks after delivery.
5-Abdominal exercises: active exercises should start few days after
labor and only static after c-section until 6 weeks after c-section.

20. Abnormal puerperium
*Sub involution is a medical condition in which after childbirth,
the uterus does not return to its normal size.
*Predisposing factors
-Multiparity
-Bad maternal health
-Caesarean section
-Uterine prolapse
-Overdistension of uterus as in twins and hydramnios
-Retroversion after the uterus becomes pelvic organ
-Uterine fibroid
*Aggravating factors
-Retained products of conception
-Uterine sepsis, endometritis

21. Symptoms:
The condition of Sub involution may be asymptomatic. The predominant symptoms are:
*Abnormal lochial discharge either excessive or prolonged
*Irregular or at times excessive uterine bleeding
*Backache and irregular cramp like pain is cases of retained products
*rise of temperature in sepsis.
Signs:
*The uterine height is greater than the normal for the particular day of puerperium.
*Normal puerperal uterus may be displaced by a full bladder or a loaded rectum.
*It feels boggy and softer upon palpation.
-Semi sitting position encourage drainage of lochia with 2 hours in prone position (only in
normal labor ) daily to encourage anteversion of the uterus and assist in prevention of RVF.

22. 1-Postpartum hemorrhage (PPH):
*Primary postpartum hemorrhage is loss of blood estimated to be
more than 500 ml following vaginal delivery or 1000 ml
following caesarean section , from the genital tract, within 24 hours
of delivery (the most common obstetric hemorrhage) and bleeding
may be due to retrained placenta, birth canal trauma, uterine atony or
blood clotting disorders.
*Secondary PPH is defined as abnormal bleeding from the genital
tract, from 24 hours after delivery until 6 weeks postpartum and it
is caused by infection or sub involution of the uterus especially of the
placental site, Retrained placental tissues as in placenta accreta, increta
and percreta as well as in submucosal fibroid polyp.

23. 2-Postpartum infections:
*Any bacterial infections of the female reproductive tract following
childbirth or miscarriage.
*Signs and symptoms usually include a fever greater than 38 °C , chills,
lower abdominal pain, productive cough, delay in uterine involution and
possibly bad-smelling vaginal discharge.
*It usually occurs after the first 24 hours and within the
first postpartum 3 weeks.
*The most common sites of infection is that of the uterus and
surrounding tissues known as puerperal sepsis or
postpartum endometritis.

24. Causes of puerperal pyrexia:
*Puerperal sepsis
*Urinary tract infection.
*Mastitis or breast abscess.
*Thrombophlebitis (superficial vein thrombosis).
*Respiratory tract infection.
*Other infections.
Puerperal sepsis: is a type of wound infection of the female genital tract that
occurs during labor or the first postpartum 3 weeks.
-Any case of puerperal pyrexia is considered puerperal
sepsis until proved otherwise.

25. Risk factors for postpartum infections:
*Anemia
*Caesarean section
*Infections of an abdominal incision or an episiotomy
*Instrumental delivery with genital tract lacerations
*Presence of certain bacteria in the vagina such as group B streptococcus
*Premature rupture of membranes
*Multiple vaginal exams
*Manual removal of the placenta
*Prolonged labor
*Breast engorgement
*Urinary tract infections
*Diabetes mellitus

26. 3-Retrained placenta:
*Retained placenta is generally defined as a placenta that
has not undergone placental expulsion (all or part of
the placenta or membranes remain in the uterus) within
30 minutes of the baby’s birth, where the third stage of labor
has been managed actively.
*Retained placenta can be broadly divided into:
-failed separation of the placenta from the uterine lining.
-placenta separated from the uterine lining but retained within
the uterus.
*A retained placenta is commonly a cause of
postpartum hemorrhage, both primary and secondary.

27. 4-Painful perineum:
*Perineal pain after vaginal delivery affects women’s recovery
from childbirth. Genital tract trauma after birth is common.
*Both episiotomy and perineal laceration are strongly associated with the presence of
perineal pain during postpartum period. Also, strong
bearing down increase the incidence of perineal pain.

29. Physical therapy for painful perineum
-Cryotherapy:
After 20 minutes of application, cryotherapy was effective in
relieving perineal pain in women in the immediate postpartum
period after vaginal birth with episiotomy (Beleza et al., 2017).
-TENS:
High frequency TENS is a safe and viable non-pharmacological analgesic resource to
be employed for pain relief post-episiotomy. The routine use of TENS
post-episiotomy is recommended (Pitangui et al., 2012).
-Low Level Laser Therapy:
LLLT can be used to enhance episiotomy wound healing, & to induce analgesic effects if
proper wavelength, energy density and exposure time are selected (Suhaila, 2011).

30. -Ultrasonic Therapy:
*US show a statistically significant result in reduction of pain and
improvement in subjects with persistent superficial dyspareunia after
episiotomy (Farzana et al., 2017).
*Therapeutic ultrasound can be used as a alternative noninvasive
treatment for relieving perineal pain and promote healing following
vaginal delivery with episiotomy to aid functional independence during
the postnatal period (Mahishale et al., 2013).
-Scar tissue mobilization:
*Scar tissue mobilization show a statistically significant result in
reduction of pain and improvement in subjects with persistent superficial
dyspareunia after episiotomy (Farzana et al., 2017).

31. -Pelvic floor exercises:
*The use of Kegel exercises after episiotomy is associated with less pain, analgesic
consumption and frequency of analgesic use (Mahmodi and Mobaraki, 2014).
*Practicing postnatal Kegel exercises had a significant effect on decreasing perineal pain
and accelerating healing of the perineal incision after episiotomy (Farrag et al., 2016).

32. A) Varicose veins:
Many women have varicose veins during pregnancy, but sometimes
this problem may stay after pregnancy. As the damage that veins
may have suffered remains irreversible.
Management:
* Avoid prolonged sitting or standing
* Bandaging
* Burger’s exercises
*Intermittent compression
-Sequential pneumatic compression therapy with the applied parameters was an
effective modality for increasing venous blood flow, reducing pain, and improving
quality of women life with varicose veins (Yamany and Hamdy, 2016).
5-Circulatory problems:

33. B) Hemorrhoids (Piles):
*Hemorrhoids are painful swelling of veins in the rectum.
After delivery - especially after a vaginal delivery and
Symptoms include pain, rectal itching, bleeding after
defecation or a swollen area around the anus.
*Many women experience them for the first-time during pregnancy
or the postpartum period for several reasons, including a rush of hormones,
internal pressure and constipation.
Management:
* Avoid constipation
* Ice gel packs application 10 min.
* Low Level Laser Therapy (LLLT)
* Pelvic floor exercises

34. 6-After pains:
*Women may experience cramping pain and discomfort following the
childbirth as the uterus contracts and returns to its pre-pregnancy size.
*These after pains are caused by involutionary contractions and usually last
for two to three days after childbirth. They are more evident for women who
are multiparous.
*Breastfeeding stimulates the uterus to contract and increases
the severity of after birth pains.
Management:
* Heat application 15-30min.
* TENS.
* Relaxation training with breathing.

35. 7-Feeding difficulties:
A) Breast engorgement:
Breast engorgement is uncomfortable swelling that results in
painful, tender breast, it is associated with an increase in blood
flow and milk supply and it occurs in the 3rd day after delivery.
Management:
* Regular feeding every 2-3 hours and 8-12 times throughout daily.
* Moist heat application for15-30min before lactation.
* Cold compresses for 10 min. to reduce swelling pain and vascularity after feeding.
* TENS: high frequency 60 HZ, for 30-60min.
* Ultrasonic therapy: Pulsed, 1MHz, 0.5W/cm2 and Duration 10:15 min.
-Ultrasound therapy helps in reduction of pain with non-tender breast which further helps the
post-partum mothers to recover better from discomforts of breast engorgement
(Priyanka et al., 2016).

36. B) Mastitis:
-Mastitis is an infection in the tissue of one or both mammary glands
inside the breast tissue.
-It is associated with pain, redness and axillary lymph nodes are enlarged
usually affects women who are breast-feeding in the 2nd week postpartum.
-Also, it has another peak in the 4-5th week postpartum.
-It is usually associated cracked nipples, allowing bacteria to enter the breast from nipples.
Management:
*Cold Application for 10 min. to reduce swelling and inflammation.
*Low level laser therapy: LLLT is a painless treatment, which appears to accelerate wound
healing of cracked nipples and ease pain (Buck et al., 2016). LLLT therapy is beneficial in
decreasing the somatic cell count and improving milk nutritional quality with an
intramammary infection (Wang et al., 2014).
*Bed rest & Continue breastfeeding.

37. C) Blocked ducts:
-Blocked or plugged ducts is a condition where a blockage in a
milk duct results in poor or insufficient drainage of the duct.
-When milk builds up behind the blockage, the concentration of
pressure in the duct may lead to local discomfort or lump
formation in the breast. It may be called non-infective mastitis.
Management:
* Moist heat application for15-30min.
* Continue breastfeeding.
* Feeding with the affected side firstly then the unaffected.
* Ultrasonic Therapy: US was a beneficial treatment for women presenting with
blocked ducts and difficulties breastfeeding. 100% (continuous) duty cycle, 1 MHz,
2 W/cm2, 10 min (Lavigne and Gleberzon, 2012).

38. 8-Diastasis recti:
*Diastasis recti is a fairly common condition of pregnancy and
Postpartum in which the right and left halves of Rectus abdominis
muscle spread apart at the body’s midline fascia (stretched linea alba)
which is a tendinous, fibrous raphe that runs vertically down the midline
of the abdomen. It extends between the inferior sternum and pubis; Linea
alba generally lacks blood supply and innervation. a gap about 2.7 cm
or greater between the two sides of the rectus abdominis muscle is considered positive sign.
*In pregnant or postpartum women, the condition is caused by
The stretching of the rectus abdominis by the growing
uterus. It is more common in multiparous women. Additional
causes can be attributed to excessive inappropriate abdominal
exercises after the first trimester of pregnancy.

39. Examination for Diastasis Recti:
*Instruct patients to perform a self-test on or
after the third postpartum day for optimal
accuracy. Until 3 days after delivery, the
abdominal musculature has inadequate tone for
valid test results.
*Patient position and procedure: Crock lying.
Have the patient slowly raise her head and shoulders off the floor or plinth, reaching her
hands toward the knees, until the spines of the scapulae leave the floor or plinth. Place the
fingers of one hand horizontally across midline of the abdomen at the umbilicus (Fig. 24.6).
If a separation exists, the fingers will sink into the gap between the rectus muscles, or a
visible bulge between the rectus bellies may be appreciated. The number of fingers that can
be placed between the muscle bellies is then documented. Because this condition can occur
above, below, or at the level of the umbilicus, test for it at all three areas.

40. *Rectus diastasis rehabilitation:
1) Kinesio tape
2) Core stability exercises:
- TA breathing
- Side plank
- Side lying leg lift
- Dead bug crunches
- Scissor kicks
- Heel slides

41. Exercises NOT suitable for Diastasis recti
1) All frontal planks
2) All crunches
3) Push ups
4) Sit ups
5) Twisting movements
6) Quadruped exercises

42. 9-Back pain:
*Back pain is a common symptom during pregnancy and postpartum
period due to multiple factors, including weight gain, changes in
posture, mechanical impact of anesthesia, bad posture during care
of baby, lactation and sleeping positions. In addition, the changing
hormone balance that relaxes the strong ligaments of the pelvis in
preparation for childbirth can affect the back.
*Many of the common causes of back pain during pregnancy
continue after delivery and women also complain of cervical,
thoracic and lower back dysfunctions.
*After delivery refereed back pain also may be due to involutionary
uterine contractions or urinary tract infections.

43. Physical Therapy Assessments for Postpartum Back pain
-Complete history.
-Active then passive physiological movements.
-Passive segmental motion.
-Passive accessory motion.
-Assessment of myotome, dermatome and reflexes.
-Special tests for some cervical disorders -Special tests for some low back disorders
*For Thoracic outlet syndrome (TOS): *For facet joint arthropathy:
-Roos test. -Quadrant test.
*For cervicogenic headache: *For sciatica:
-Flexion rotation test. -Straight leg raising test.
-Piriformis test or active piriformis test.
*For Spondylolisthesis:
-Test of anterior lumbar spine stability.
-passive lumbar extension test.

44. Physical Therapy Treatments for
Postpartum Back pain
-Hot packs & Kinesio tape
-Ultrasonic therapy & LLLT.
-TENS & Interferential currents.
-Myofascial release techniques & IASTM.
-Core stability exercises.
-Postural correction techniques.
-Gentle mobilization techniques & MWM.
-Pelvic floor and pelvic rocking exercises.
-Gentle stretching exercises.
-Abdominal and hip extensors strengthening exercises.
-Ergonomic considerations.
-Avoid spinal manipulation to postpartum women.

45. 10-Symphysis pubis dysfunctions:
*Symphysis pubis diastasis is a rare cause of pelvic pain in pregnancy
but may be underdiagnosed. It is a complication of pregnancy and
vaginal delivery in which the pubic symphysis separates, resulting in
acute pelvic pain, and may lead to severe long-term consequences.
Provocative tests (when positive, they are helpful in diagnosing SPD):
*Patrick’s Faber sign:
The test is positive when there is pain in
either sacroiliac joint or symphysis pubis.
*Active straight leg raise (ASLR)
*Flamingo test: Pain at symphysis when
standing on one leg is a positive sign.

46. 11-Sacroiliac joint dysfunctions:
*Sacroiliac dysfunctions are common during pregnancy and these
dysfunctions may continue after delivery (postpartum period).
*pregnancy-induced bone marrow edema at the sacroiliac joints, as a
result of prolonged mechanical stress, was present in 63.3% of women
during the early postpartum period and may mimic sacroiliitis of axial spondylarthritis.
Provocative tests (when positive, they are helpful in diagnosing SI dysfunctions):
*Cluster of Laslett: *Passive extension and medial rotation of ilium on sacrum
-Posterior thigh thrust *Passive flexion and lateral rotation of ilium on sacrum
-Gapping test *Thomas test
-Compression test *Piriformis test
-Sacral thrust test *Leg length discrepancy
*Functional test of supine active straight leg raise
*Functional test of prone active straight leg raise

47. Physical Therapy Treatments for Sacroiliac and
Symphysis pubis dysfunctions
-Reassurance and Relaxation training.
-Hot packs:15-30 min. or Cold packs:10 min.
-Ultrasonic therapy ( Pulsed, Not Continuous )
-phonophoresis and Lidocaine iontophoresis.
-TENS & LLLT.
-Muscle energy tech. & trigger points release.
-Positional release (strain counter strain tech).
-Gentle mobilization techniques.
-Lumbopelvic supports and Kinesio tape.
-Core stability exercises.
-Stretching exercises.
-Strengthening exercises for ipsilateral hip extensors and contralateral latissimus dorsi.

48. 12-Coccydynia:
*Coccydynia is inflammation localized to the tailbone (coccyx).
*Symptoms and signs of coccydynia include focal dull aching pain and
tenderness at the tailbone.
*Postpartum coccydynia is pain that appears as soon as a sitting position
is adopted after delivery. Coccyx morphology, body mass index, vaginal delivery,
instrumental delivery, multiparity, advanced maternal age and short perineum are risk factors.
*Childbirth is usually related to damage of the sacrococcygeal ligaments during vaginal
delivery and the passage of the fetus through the birth canal may cause acute trauma to the
coccyx, this can be further aggravated by forceps delivery.
*Giving birth is one of the most common causes of coccydynia.
The coccyx becomes more flexible towards the end of pregnancy.
This allows coccyx, and sacrum, to bend and give way during labor.

49. Evidence of Physical Therapy
Treatments for coccydynia
*Patients with coccydynia are initially advised to avoid
provocative factors. Initial treatment includes ergonomic
adjustments such as using a donut-shaped pillow or gel
cushion when sitting for a long period of time.
*Stretching of piriformis and iliopsoas muscles and
Maitland's rhythmic oscillatory thoracic mobilization over
the hypomobile segments for 3 weeks, 5 sessions per
week showed significant improvement in pain pressure
threshold and pain free sitting in patients with
coccydynia (Mohanty and Pattnaik, 2017).

50. *Extracorporeal shortwave therapy was more effective and satisfactory
in reducing discomfort and disability caused by coccydynia 3,000 shock
waves per session of 2 bar at 21 Hz frequency directed to the coccyx
(Haghighat and Asl., 2016).
*Adequate pelvic floor muscle training can produce cranial movement of the coccyx tip
(Fujisaki et al., 2018).
*Combined manual therapy and corticosteroid injection were more effective in the
treatment of Coccydynia and patients following the treatment were completely pain free at the
end of the year (Chakraborty, 2012).
*Ultrasound therapy: Intensity-2w/cm2, Frequency-3MHZ,
Mode- continuous and Duration-10min. is an excellent non pharmacologic,
noninvasive method for alleviating post partum coccydynia (El-Mekawy et al., 2006).

51. 13-Dequervain’s tenosynovitis:
*De Quervain's tenosynovitis is a common wrist disorder involving
the abductor pollicis longus and extensor pollicis brevis tendons of
the first dorsal compartment.
*Mild symptoms may be present during the later stages of pregnancy
and then increase markedly at or shortly after delivery. Patients who
have persistent symptoms have reported that the activities of the
infant care often aggravate the condition.
*Finkelstein's test is a test used to diagnose de Quervain's
tenosynovitis in people who have wrist pain.
Classical descriptions of the Finkelstein's test are when the examiner
grasps the thumb and ulnar deviates the hand sharply. If sharp pain
occurs along the distal radius, it is a positive sign.

52. Physical therapy for De quervain’s tenosynovitis
-Cryotherapy: for 10 min.
-TENS: If acute – high frequency TENS for 3o min.
If chronic – low frequency TENS for 15-20 min.
-Ultrasonic therapy:
If acute – 3MHZ, 0.5W/CM2, Pulsed 25% duty cycle.
If chronic –3MHZ, 1W/CM2, continuous 100% duty cycle.
-Phonophoresis and Iontophoresis.
-Low Level Laser Therapy (LLLT).
-DTF and stretching exercises.
-Mobilization with movement technique (MWM).
-Graduated strengthening exercises.
-Splints and Ergonomic considerations.
-Kinesiotaping.

53. 14-Carpal tunnel syndrome:
*Carpal tunnel syndrome (CTS) is an entrapment neuropathy caused by
compression of the median nerve as it travels through the wrist's carpal tunnel.
and it is the most common nerve entrapment neuropathy, accounting for
90% of all neuropathies.
*The main symptoms are pain, numbness and tingling in the thumb, index finger,
middle finger and the thumb side of the ring finger. after a long period of time the
thenar muscles may waste away.
*Carpal tunnel syndrome (CTS) is a frequent complication of pregnancy,
But it may persist in 15% of postpartum women due to care of baby.
*The Phalen's test, reverse Phalen's test and Nerve conduction studies
(NCS) are useful in diagnosis.

54. Physical therapy for Carpal Tunnel Syndrome
-Ice pack: for 10 min.
-Contrast baths: hot water (45°С) for 3min. then cold water (15 °С) for 1min.
and repeat for 3 times, Begin and end with hot water.
-Ultrasonic therapy (Pulsed or Continuous) and phonophoresis.
-TENS.
-Low Level Laser Therapy (LLLT).
-Pulsed magnetic field therapy (PMFT).
-Myofascial release technique and DTF.
-Gentle stretching exercises.
-Carpal bone especially Scaphoid mobilization.
-Median nerve mobilization.
-Strengthening exercises for hand grip & ant. forearm ms.
-Ergonomic considerations, Splint & Kinesiotaping.