This post is part two of a post outlining some of the key concepts I use within my practice, to answer the questions of ‘what does a women’s health physio do, and how does she think and reason her treatment for the Pregnant Pelvis?. Part one looked at loading, and the extra consideration required when dealing with pregnant ladies. Part two will finish up with pain science theory, exercise in pregnancy and education.
Pain science theory is key to contemporary physio – MSK, neuro or otherwise. But within Women’s Health there are many other things to consider. Let’s remember that hormones have a role to play. Not only the physiological effects but those on our fears and emotions to cause some irrational outbursts. Thankfully, I’ve skipped all these: Ady, my family and friends haven’t had a hard time AT ALL….(this is my official apology! Soorrrry).
But there’s also the rational, genuine fears:
‘It’s only 5 months and my back hurts, what happens if I do something and it gets worse?’
‘I’m not managing now, what’s birth going to be like?’
‘what happens if this doesn’t go away after birth, what kind of mum will I be?’
‘Am I hurting the baby by moving weirdly or exercising?’
These are genuine things that have ran through my head, and sometimes it’s hard to decide what rational and what’s irrational, but either way, it nearly stops me doing things that ultimately help me feel physically and emotionally better. Now I should know better being a physio, so just imagine the effects on the general populations approach to movement…
There are lots of decent resources online for to help us address this pathophysiological component of pain: Peter and Jack on youtube (whatever happened to Jack I wonder), pain-ed.com and in particular the video regarding myths and back pain, Lorimer Moseley’s lecture involving the snake bite on you tube and of course, Explain Pain (the book). With so much going on for ladies at this time causing both rational and irrational worries, maybe a chat and coffee is the best starting point rather than 3x12 squats.
Which leads me to exercise. Put simply, exercise works. Unfortunately there are so many sources of information for the pregnant women which suggest different things regarding exercise. Regrettably this can include old wives tales and emotional rather than scientific advice from over protective friends or family. As a result of juggling all this information, emotions and being overwhelmed, the twisted logic could lead to the assumption that doing nothing is safer, and a journey into a sedentary pregnancy state. There are some very good medical reasons for not continuing exercise during pregnancy, and there is reason to be cautious when starting new exercise during pregnancy. But if only the message was clearer that continuing aerobic and strength and conditioning exercise is an integral part not an optional part of leading a healthy lifestyle in pregnancy, then issues of gestational diabetes mellitus, obesity, shoulder dystocia, pre eclampsia, dyspnoea and not to mention pelvic pain could be significantly addressed.
And I’m not talking starting 5km runs or learning to climb. Just the basic strength and conditioning exercises that maintain strength, control and balance coupled with good aerobic conditioning. The Royal College of Obstetricians and Gynaceologists suggests that reasonable goals of aerobic conditioning in pregnancy should be to maintain a good fitness level without trying to reach peak fitness level or train for athletic competition. Key to this is that prevention being better than cure, so preparation is key. It’s my firm belief that you should make a change in your exercise lifestyle once you start taking folic acid three months prior to planning to conceive. I think a little leaflet inside pre pregnancy supplement packs would go down a treat. Or rather than the squat challenge on facebook, an encouragement to do ‘folic squats’: squatting for a healthy pregnancy.
Additionally, exercising during pregnancy helps maintain a healthy weight. Weight gain is an inevitable part of blooming, with your growing foetus and 40% increased blood volume to name just two reasons. But its commonplace to see extra maternal weight being put on. The tagline ‘you’re eating for two’ is not tremendously useful, and not true. Not only is there extra load translation requirements through a struggling to stabilise ‘softening’ pelvis, but it is also putting more strain through a fatiguing pelvic floor. Incontinence can strike, and who wants to exercise when they leak whilst doing step ups?! Another vicious cycle! But on the whole preventable or at least the risk can be reduced with good planning.
It is important to remember that there are some conditions that will outright stop the ability to exercise, and in which case maintaining a healthy weight will be very hard. The advice I give is not to make expectant mothers to feel bad but at the same time it has almost been normalised that modern mums will put on lots of weight above and beyond the weight of the baby and other products. A great way of reducing the risk of pelvic pain is to quite simply manage your weight as best you can – with professional advice, exercise or careful diet planning. Ask your midwife.
And of course a reward of a cheeky lindor/ double decker or bowl of popcorn now and again is completely acceptable…
With a ‘clicking’, ‘grinding’, or ‘giving way pelvis’ that a baby is due to come out of, encouraging pregnant women to participate in exercise is not always the easiest thing to do in clinic, because they do sound like things that are not going to respond positively to movement. So therefore it’s important that coaching and education is utilised well to engage, and this may take a bit more time. I like to highlight and not underestimate to the lady the relatively quick changes in load, body shape, biomechanical strain, and therefore form and force closure abilities of the pelvis that can all create pain at this time. I ask, ‘when else can you think of in a person’s life these changes occur so dramatically and quickly?’ This is not meant to scare, but to emphasise that this is enough to warrant the level of pain they are experiencing, to help rationalise it and develop strategies to reduce and manage it.
Coaching and educating is a skill, and one I would certainly say I’m still in the process of perfecting. Cognitive Behavioural Therapy (CBT) theories and frameworks can be very useful approaches. Mike Stewart has some great resources and information on the use of good language during sessions (if you get the chance to see Mike, do so, his delivery of information is just so good). Finally, I’d recommend checking out one of Ady’s old colleagues Bradley Scanes article which gives a nice introduction to motivational interviewing on http://www.paintoolkit.org/news/article/motivational-interviewing-a-way-of-talking.
What specific strength and conditioning exercises do I use? This varies with clinically reasoning for the individual’s situation. I wanted to run during pregnancy so I needed running economy exercises, but these wouldn’t be used for the expectant mum who want to be able to do long country walks. For specific strength and conditioning exercises to address the many onslaughts upon the pregnant pelvis, the gluteal muscles are key stabilising targets at this time. Activating these can help to reduce inefficient compensatory stabilising mechanisms such as over recruiting the adductors and the pelvic floor. Reiman (2012) did a great systematic literature review displaying the percentage of max voluntary isometric contraction of glut max and med during varying exercises, well worth a look to give guidance on varying intensity exercises dependant on the lady’s situation. It’s interesting to consider that the contemporary view of exercise through pregnancy is ‘core based’ and quite gentle, which doesn’t really target the gluts with resistance. Squats, deadlift variants, step ups, single leg control work and glut band work should all be in a well prescribed exercise set. I like the single leg work to be in standing if at all possible for the functional proprioceptive value but also for weight bearing. Weight bearing exercise is not only good functional loading practice for the pelvis but it has been shown to reduce the length of labour and decrease delivery complications.
Aerobically, most guidelines advocate the upper range of 60-70% maximal heart rate for sedentary women prior to pregnancy and 60-90% upper range for those wishing to maintain fitness during pregnancy. The Talk Test is also widely used as a ladies heart rate increases during pregnancy and so could be misleading to them. On the Borg Scale of Perceived Exertion ‘moderate exercise’ should be between 3-5; and you should be able to carry on a conversation. Not only does our heart rate increase but so too does our rate of breathing. Ladies need educating to expect this otherwise it could be a scary deterrent.
Finally, the Pelvic Obstetric and Gynaecology Physiotherapy special interest group have a great read; ‘Fit and safe exercise for the childbearing years’ which nicely categorises ladies into four types of exerciser, giving recommendations on suitable types of exercise for them. It is however advised to avoid exercise that may put the foetus at risk of trauma…so no snowboarding holiday for me this year (and so the sacrifices begin…). Some benefits to exercise in pregnancy which can be a selling point that I highlight to ladies, is that those who exercise experience less insomnia, stress, anxiety and depression.
So there you have it. These are my own views, using the research available, and of course not everything can be conveyed well in a blog, but hopefully it’s found to be useful.
If you are a pregnant lady or planning to be; in general exercise is good in pregnancy but there are some things to consider so why not book yourself in for a bespoke assessment and advice session at Rowan House with myself? Hopefully the message has gotten across that a Women’s Health Physiotherapist specialises in providing individualised advice and support to keeping you active and able in you pregnancy and beyond. Some information can be shared by email, but obviously there is a limit to not being able to see you physically.
I also run pregnancy and postnatal pilates classes, designed to address all of the above, with a small class of 6 ladies, it gives the ability to tailor exercises and education to your individual needs. For more information or to find out how to book, click on the ‘services’ tab above.
Also look out for the upcoming blog that aims to explain these ideas in a lay fashion. It’ll be entitled ‘folic squats’.
Do you have any other queries about women’s health physio, or something you’d like to see in a blog post? Why not drop me an email and I’ll try muster something up.
Bye for now x
Royal College of Obstetrics and Gynaecology – Exercise and Pregnancy -https://www.rcog.org.uk/globalassets/documents/guidelines/statements/statement-no-4.pdf
Pelvic Obstetric and Gynaecology Physiotherapy – Fit and Safe Exercise in Pregnancy Lealfet - http://pogp.csp.org.uk/publications/fit-safe-exercise-childbearing-year
‘Peter O Sullivan and Jack’ video. Accessed on 22.2.2016 on: https://www.youtube.com/watch?v=j4gmtpdwmrs
‘Back pain. Separating fact from fiction’ video. Accessed on 22.2.2016 on: http://www.pain-ed.com/blog/2015/09/22/back-pain-separating-fact-from-fiction/
‘Pain. Is it just all in your mind?’ video accessed on 22.2.2016 on https://www.youtube.com/watch?v=-3NmTE-fJSo
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Scanes, B (2015). Motivational interviewing: a way of talking accessed on : 22.2.2016 at http://www.paintoolkit.org/news/article/motivational-interviewing-a-way-of-talking