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Musculoskeletal Issues Arising from Pregnancy

As your physical body changes and accommodates to the needs of your growing baby, you may experience discomfort and aches and pains.? Physical therapy is an effective way to help you manage your pain and can offer you a variety of ways to make your pregnancy more comfortable.? During your pregnancy, especially in the third trimester, your back may start to feel uncomfortable.? This can be due to relaxin, a hormone released during pregnancy, which causes the ligaments to be a little lax and can pull the lower back and pelvis in different directions and put strain in different areas causing pelvic, hip or back pain.? This can also be due to the pressure of the baby, especially if you are having multiples.? Other musculoskeletal issues that can arise during pregnancy are nerve compression syndromes such as carpal tunnel, tendonitis, circulatory problems, spinal problems, pelvic joint pain such as osteitis pubis, coccyx/tailbone pain, groin pain and sacroiliac pain. Others include foot/ankle pain, abdominal pain such as scar pain and diastasis recti, heartburn, morning sickness/nausea, urinary problems and blocked milk ducts. These will all be explained in detail in the following sections.

Treatments during pregnancy?

Some treatments in physical therapy can address these aches and pains during your pregnancy.? There should be no modalities used such as ultrasound or electric stimulation as those are contraindicated with being pregnant.? However, there are many other treatments that can help.? The first and most important is stabilization exercises, which include the core and pelvic floor muscles which help to stabilize the pelvis and lower back during movement.? Some women are nervous to exercise during the pregnancy, but it is very safe.? According to the American College of Obstetricians and Gynecologists (ACOG), they suggest that women should exercise 3-4 times per week for 15 minutes at a time at a heart rate of 140 beats per minute. ??Exercise includes walking, doing yoga, swimming, and pelvic floor/core exercises. These exercises will be outlined below.

Pregnancy Exercises

Quadruped arm/leg? Start position: On your hands and knees with back completely flat and arms and legs shoulder width apart, tilt pelvis underneath you (tuck your tail) to keep your back in alignment. Repeat on the other side.? End Position: Contract core and pelvic floor muscles, bring arm up slowly to shoulder heighth, maintaining straight low back with pelvis tucked under. Do 10 reps. Repeat on the other side. Alternate End position: Bring leg up slowly to hip heighth, maintaining straight low back with pelvis tucked under.? Do 10 reps. Repeat on other side.

Opposite arm leg Same starting position as quad arm/leg End position: Contract core and pelvic floor muscles, bring opposite arm and leg up slowly to shoulder and hip heighth, maintaining straight lower back alignment with pelvis tucked under and do not let your hips drop. Do 10 reps. Repeat on the other side.

Ball Exercises-posterior pelvic tilt? Start position:? Sitting on the ball, with legs spread apart and center of gravity evenly distrubted on the ball with hands on your hips. End position:? Contract core and pelvic floor muscles and tuck your pelvis underneath and ?tuck your tail.?? Back should be as flat as you can get it. Do 20 reps.

Ball Exercises- Marching? Start Position: Sitting on the ball, with legs spread apart and center of gravity evenly distrubted on the ball with hands on your hips. End Position: Contract core and pelvic floor and bring knee towards the ceiling keeping pelvis tucked underneath.

Ball Exercises- Leg Extension? Start Position: Sitting on the ball, with legs spread apart and center of gravity evenly distrubted on the ball with hands on your hips. End Position: Contract core and pelvic floor, slowly bring leg up in the air with the knee locked to hip heighth and slowly lower down.? Do 10 reps. Repeat on the other side.

Side planks Start Position: Laying on your side with your elbow on the ground at 90 degrees and knees bent End Position: Contract core and pelvic floor, tuck your tail and bring your hips straight up in the air with pressure on your knees and forearm. Hold for 10-15 seconds, then relax.? Repeat 5 times, then repeat on the other side.

Calf Stretch? Standing against the wall with arms extended, bring one leg back and keep it straight with one leg forward with the knee bent.? You should feel a stretch in your calf that is back.? Hold for 30 seconds.? Repeat on the other side.

Partial Wall Ball Squat Standing against the wall, with ball at your low back and hands on your hips, spread feet shoulder width apart.? Slowly bend your knees to about 45 degrees, contract core and pelvic floor and slide the ball down the wall.? Do 20 reps.

Standing Wall Stretch Starting Position: Standing with back against the wall and feet out from the wall about a foot with knees bent, bring arms up and out to the side with elbows at 90 degrees. Ending Position: Bring hands toward your head and straighten out knees. ?Repeat 20 reps.

Butterfly Stretch Sitting on the floor, bend both knees and pull feet in facing one another and try to pull knees towards the floor.? You should feel a stretch in your inner thighs.? Hold 30 secs, repeat twice.

Deep Squat Stretch Standing against the wall, spread legs apart and slide down the wall with knees out and bend your knees as much as you can.? You should feel a stretch in your inner thighs and pelvic floor.? Breathe in and out deeply 5 breaths.

Rising Sun Stretch Starting Position:? Laying on your back, bring your L leg over your R leg with knee bent and touching the floor.? Then bring your L arm over to your R with hand on the mat.? Ending Position: Then extend your L arm over to your L side and try and lay your L arm on the ground.? You should feel a good stretch in your arm, back and hip. Hold for 30 seconds. Repeat on the other side.

Back Stretch? Starting Position: Standing, bending over at the hips, put arms on counter or shelft with arms straight. ?Keep back flat with pelvis tucked underneath to avoid back arching. Ending Position: Now bring one arm forward with palm facing down, keeping back flat and legs as straight as you can.? Hold 10 seconds and repeat on the other side.? Repeat 5 times each.

Some other treatments for pregnant women who have pain include wearing SI belt, massage, and proper body mechanics.

The pelvic girdle is a complex ring of joints, ligaments, and muscles. The three main bones of this region, two ilium and the sacrum, meet together to form three joints. These areas are the pubic symphysis and two sacroiliac joints. These joints have very broad based surfaces that allow them to have some movement and transfer large loads placed on the joints during activity.

In order for these bones to have some movement between one another when we walk, bend, and move the way we do, they must have an outside force to stabilize them. This stabilizing force is made up of the ligaments and muscles that control the amount of movement. Stabilization by the muscles is provided by four central muscle groups, which include the pelvic floor muscles, multifidi, transverse abdominus, and psoas major. If these muscles or ligaments are not working properly, exercise will help.? In addition, a sacroiliac belt may help to stabilize the lower back. Here is a picture of what one looks like.

Prior to labor, there are a few different treatments that can be done to make the delivery faster, not as painful and easier all together.? ?Those treatments include perineal massage and birthing positions with use of EMG.

Perineal Massage

Perineal massage is the gentle stretching and massaging of the skin between the anus and vagina (perineum) during the last few weeks of pregnancy. This massage has been shown to reduce the incidence of episiotomy and perineal tears during birth. The benefits of doing the massage are that the skin becomes more supple and elastic and as a result reduces the possibility of perineal tearing or an episiotomy. ?The massage prepares you for the feelings of pressure and stretching when your baby?s head starts to crown. Having an idea of what these sensations are like enables you to relax and as a result this can lead to a quicker birth. Tension will delay your baby?s descent. Perineal massage during labor helps to ease the tissues around the baby?s head as it is crowning and clearly benefits both mother and child. This area is very sensitive during the birth so it is often more helpful for the mother to use perineal massage during this time.

Technique for perineal massage:

?The following directions are for the expectant mother. But partners can take their cue from this as well.

• Wash hands, and find a relaxing place to do the massage (bathroom, bedroom, where ever you are comfortable)
• Sit in a comfortable position. (A warm bath or warm compresses on the perineum for 10 minutes before massage may help with relaxation.)
• Put a water-soluble lubricant (KY Jelly, etc.) or Vitamin E oil on thumbs and perineum.
• Place thumb just inside of the vagina.
• Press downward towards the rectum and to the sides at the same time until a very slight burning, stinging, or tingling sensation is felt
• Hold the pressure for about 1 minute
• Breathe deeply and slowly and try to consciously relax the muscles.
• Keep pressing down with the thumb and slowly and gently massage back and forth over the sides of the vagina in a ?U? movement for 3 minutes.
• Relax and repeat once.

Another treatment that can be useful to the expectant mother is going over birthing positions with use of EMG. The EMG is biofeedback that can detect tone in the pelvic floor.? Certain positions are more comfortable and have less tone on the pelvic floor than others.? A women?s health physical therapist can help with using biofeedback and testing out different positions to find the best, most comfortable position for you to have your baby in.? This can be an important step to decrease pain and tearing during the labor process. Also, if you have any medical problems such as low back pain or neck pain, different positions are better than others.?

Treatments post-pregnancy

After you have your baby, there are some treatments to ease the pelvic floor pain and to help it heal.? If you tear or have an episiotomy, there is some scar management that can be done.? You can work the scar with your fingers to decrease scar tissue and adhesions from forming. Using your finger just below the vagina, you can make circles on the scar or move it back and forth.? You can also stretch it similar to the perineal massage.

After having a baby, your pelvic floor and core muscles become very weak.? It is essential that the mom work on pelvic floor strengthening, stretching, use proper body mechanics and take care of baby while taking care of mom.?

Pelvic floor strengthening includes doing a kegel, where you contract your pelvic floor and pull vagina up and in.? Do this exercise during the day as much as you can and anytime you lift.? Every time you lift or bend over, this increases intra-abdominal pressure in your abdomen and places stress on your pelvic floor and can cause more problems such as leaking.?

Kegels are an essential exercise pre and post-partum in addition to other core and pelvic floor strengthening.? Your core and pelvic floor muscles become very weak with pregnancy and labor and it is quite important to strengthen them again.? Some exercises post-partum that will help strengthen the core is tummy tucks, heel slides, bridges and pelvic tilt.

Download Exercises

In addition to strengthening the pelvic floor and core, posture exercises also are useful.? They include shoulder blade squeezes, upper back stretching and wall slides.

Download Stretches

It is also important to watch your posture and body mechanics while holding, feeding and changing baby. Make sure you keep baby close to your body, lift properly using your legs and keep pelvic floor contracted as much as you can.

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