Musculoskeletal Problem in Pregnancy

Musculoskeletal problem in pregnancy

Presented by : VinodB.P.T 4th year

Roll no : 0071052607

IntroductionPregnancy¤ Divided in to Three trimester - 40 weeks

Labor ¤ Divided in to three stage

April 10, 2023 musculoskeletal problem in pregnancy 2

Pregnancy


Changes during 1st trimester (0 to 12 week)

Implantation of the fertilized ovum

Nausea or vomiting ,fatigueness and more frequently urination

Breast size increases

Small wt gain of 0 to 1455g

Fetus is 6 to 7cm long and wt approx 20g


Changes during 2nd trimester (12-28week)

Pregnancy visible

Mother feel movt.

Nausea and fatigue will disappear

Fetus is 19 to 23 cm (14 inches) long and 600g wt


Changes during 3rd trimester (29-40week)

Uterus is large and regular contractionCommon complaints are ¤ Frequent urination ¤ Back pain¤ Leg edema and fatigue¤ Round ligament pain ¤ Shortness of breadth and constipation

By the time of the birth baby will 33 to 39cm long (16-19inches) and 3400g wt


Labour Stage 11. cervical dilation phase (0-3cm)2. Middle phase (4-7cm)3. Transition phase (8-10cm)

Stage 21. Fetal descent2. Expulsion of fetus

Stage 3 1. Placental phase 2. uterine involution


Anatomical and physiological changes of pregnancy


Pregnancy wt changesRespiratory system changesCardiovascular systemUrinary system changesBreast changes Skin changesReproductive system changes

Contd…Nervous system changesEndocrine system changesGastrointestinal system changesMusculoskeletal system changesThermoregulatory system changesPosture and balance changes


1. Pregnancy wt gain

Fetus 3.36 - 3.88 kg 7.5-8.0 lb

Placenta 0.48 - 0.72 kg 1.0 – 1.5 lb

Amniotic fluid 0.72 - 0.97 kg 1.5 – 2.0lb

Uterus and breasts 2.42 – 2.66 kg 5.0 - 5.5lb

Blood and fluid 1.94 - 3.99 kg 4.0 -7.0 lb

Muscle and fat 0.48 - 2.91 kg 1.0 – 6.0lb

Total 9.70 -14.55 kg 20.0 -30.0lb


Total wt gain for single fetus

2. Respiratory system changesEdema and tissue congestion of upper respiratory tract occurs in early in pregnancyChanges in rib position The subcostal angle progressively increasesThe anterioposterior and transverse chest diameter increase by 2cm (1inch)Total chest circumference increases by 5-7 cm Diaphragm is elevated by 4 cm (1.5inches)The respiratory rate unchages but the depth of respiration


Contd…Tidal volume increases by 40% but total lung capacity is unchanged15-20% increase in oxygen consumptionWomen feel breadthlessnessIt seems that harmone relaxin soften the costochondral junction and render them more mobile Women complain of costal margin pain or rib ache


3. Cardiobascular systemBlood volume increses 35-50%(1.5-2litres)

Plasma increases greater than RBC increases

Venous pressure in the lower extremities

The heart size increases and the heart is elevated

Heart rhythm disturbances

Heart rate usually increases 10 to beats per minute


Contd…Cardiac output is increases 30-60%Blood pressure is decreases early in the 1st trimesterAlthough CO increases but BP decreases because of venous distensibility


4. Urinary systemIncrease in size and weight , and dilation of renal pelvis length of kidney increases by 1cm(0.5inch)Increase in urine outputDiabetes may be first diagnosed in pregnacy (gestational diabetes)Urethrovesical angle altered The intra-abdominal pressure raised


Contd…Pelvic floor may become lax and more elasticLate in pregnancy there may be urge and stress incontinence


5. Breast changes Tenderness and tingling may be experiencedBreast enlarge and total breast wt increase 400-800gThis is stimulated by the rising level of the oestrogen , progestrone and relaxin harmoneThere is increase in blood supply and increase in number , size and complexity of the ducts


6.Skin changes

Pigmentation is seen in breast, linea alba , vulva and the face Blotches which occur on the fore head and cheeks are called ‘chlosama’ or ‘the mask of pregnancy’‘Stretch marks’ or ‘striae’ can develop over buttock , abdomen Increase in the blood flow to the skin


7.Reproductive system changesAmenorrhoea is the one of the first sign of pregnancyCervical changes gradual which in the final weeks involves the softening ,greater distensiblity and ultimate dilation of the cervixBurst of irregular ,short usually painless contraction become more evident and systematics. They are called ‘Braxton Hicks contraction


Contd…The fetal heart sound can be heard using :■ Sonic aid -: 14weeks■ Stethoscope-: 24-26Weeks

Fetal movement are usually felt ■ Multigravida :16-18 weeks■ primigravida: 18-20week


8. Nervous system changes mood lability ,anxiety , nightmares , sight reduction in cognitive ability and amnesia Water retention quite frequently causes unusual pressure on nervesWomen complains of symptoms indicating traction in nerve


9.Endocrine system changesProgesterone , oestrogen and relaxin harmone is the most important harmone for pregnancyEffect of oestrogen:1. Reduction in tone of the smooth muscle2. Increase in temp (0.5ºC)3. Reduction in alveolar and arterial Pco2 tension,

hyperventilation4. Development of the breasts alveolar and glandular

milk- producing cells5. Increased storage of fat


Contd…Effects of oestrogens 1. Increase growth of uterus , breast ducts ,level of

prolactin to prepare breast for leceration2. May prime receptor sites for relaxin , e.g. pelvic

joint , joint capsule , cervix3. Increased water retention4. Higher levels result in increased vaginal glycogen


Contd…Effect of relaxin1. Gardual replacement of collagen in target tissues

(e.g. pelvic joints, joint capsule, cervix)2. Inhibition of myometrial activity during

pregnancy3. May have a roll in cervical ripening, mammary

growth


10.Musculoskeletal system changes

Abdominal muscles are stretch up to elastic limit by the end of pregnancy The shift in the COG also decreases the mechanical advantage of the abdominal musclesDecrease in ligamentous tensile strength due to change relaxin and progestrone levels joint hypermobilty or joint laxity


Contd…Pelvic floor drops as much as 2.5 cm (1 inch)Stretch and compression of the pudendal nerveLumber and thoracic curve increasedThe distance between the two rectus abdominis muscles widen and the linea alba split under the strain(diastasis recti)In the 3rd trimester- increased water retention which result in a varying degree of oedema of ankles and feet


11.Thermoregulatory system changes

Basal metabolic rate and heat production increaseFasting blood glucose level in pregnant women is lower than in nonpregnant women


Posture and balance changesCOG:■ The COG shift upward and forward ■ This requires postural compensation for balance and

stability■ The shoulder girdle and upper back become rounded with

scapular protracted and upper extremity internal rotation■ Cervical and lumbar lordosis increases ■ Wt shift toward heel■ Change in posture do not correct spontaneously after child

birth


Contd…Balance:■ Increase in wt and redistribution of body mass ■ The woman usually walks with a wider base of

support and increased in ER■ Some activities may be difficult like walking ,

stooping , stair climbing etc■ Some activities may become inadvisable such as

aerobic dancing and bicycle riding


Musculskeletal problem


Some common problems 1. diastasis recti (DRAM)2. Low back pain and pelvic pain

a) Postural back pain b) Sacroiliac back pain

3. Varicose veins4. Pelvic floor disfunction5. Joint laxity6. Osteitis pubis ,diastasis of symphysis pubis7. Thoracic spine pain


Contd…8. osteoporosis9. Coccydynea10.Cramps11.Compression of nerves


DRAMRectus abdominis muscle separates in midline.Defined as gap between rectus abdominis of greater than 25mm palpated just superior to umbilicus.Separation may occur during pregnancy or expulsive stage of labour.Occur in pregnancy due to hormonal effect on connective tissues.Less common in female with good abdominal tone.Continues past 6week post partum period.May produce LBA, less protection to fetus, herniation of abdominal viscera through separation in abdominal wall.


Management Abdominal muscle strengthening exercises.

Pelvic tilt exercises.

Abdominal support or binder

In extreme cases, cosmetic surgery called tummy tuck by creating folding of linea alba and suturing together. This creates a tighter abdominal wall.


Low back pain and pelvic pain Pain commonly due to postural changes of pregnancyPostural back pain usually worsen with muscle fatigue from static posturesSacroiliac symptoms may be caused by ligamentous coupled with postural adaptation and muscle imbalance pain is usually localized to the posterior pelvis and is described as stabbing deep into the buttocks distal and lateral to L-5/S-1Pain radiate into the posterior thigh or knee but not into the foot


managementacute condition- bed restFind the selection of the position especially in toileting , washing and eating mealsDiscontinue the activity which exacerbate the conditionPain and muscle spasm respond well to gentle heat and massage given in the side lying Facet joint dysfunction – gentle mobilization may be appropriateWhen pain continues despite all efforts - TENS


Varicose veinsVaricosities are aggravated in pregnancy by the increased uterine weight Venous stasis in the legs and increased venous distensibilityMild discomfort to severe pain in the lower extremities


managementDiscomfort – exercises may be modified Elastic support stockings should be worn to provide an external pressure gradient against the distended veinElevation of the lower extremities


Pelvic floor disfunctionThe process of the labour and vaginal delvery can produce significant trauma to the neuromuscular junction prolapse Urinary or fecal incontinence Pain / hypertonus


managementTherapeutic exercise and pelvic floor rehabilitation Once coordination has improved , the client progresses to integration of pelvic floor activity with ACLs Lumbar stabilization, and other functional exercisesSuperficial heat ,ice , and manual technique TENS


Joint laxityAll joint structure are increased risk of injury during pregnancy and during the post partum periodThe tensile quality of the ligamentous support is decreasedChances of injury is increased


managementTeach the woman safe exercises to perform during the pregnancy year Suggest nonweight – bearing or less stressful aerobic activities such as

Swimming , walking etc


Osteitis pubis ,diastasis of symphysis pubis

The width of the symphysis pubis increases 4mm – 9mm Transient and incapacitating pain in and around the joint and radiating down the medial aspect of the thighMovt. such as turning over in bed and hip abduction cause pain


Contd…SYMPTOMS :-■ PAIN in area of symphysis can be central, U/L, radiating

down medial thighs and accompanied by LBA and SI joint pain.

■ Difficulty with walking, with certain movements rolling over bed, low squatting movements, getting in/out of car.


Contd…SIGNS :■ Pain on palpation of symphysis.■ Pain on unevenly applied pressure on both ASIS.■ Pain on U/L weight bearing.■ Waddling gait.■ Light hip adduction.■ Inability to freely flex hip.■ Pubic diastasis may be present but can be

different to palpate if pain is severe.


Management Acute condition – bed rest with the legs adducted and flexedBinding the hips with a long roller towel may give some relief Walking frame , sticks or crutches should be supplied whenever necessary Ice packs over the painful area 2-3times per day


osteoporosisIt is a rare in pregnancy PTist must be aware of back and hip problemBack pain, together with vertebral collapse and consequent loss of height


CoccydyneaPainful coccyx and neighbouring sacral areaCoccyx is loosely articulated with sacrum and moves backwards as parturition take placePost natal passage of fetus through the birth canal can cause trauma to the regionSymptoms : pain is facilitate on sitting, arising from chairSign: pts sits down slowly often sitting


Contd…SYMPTOMS :-• Pain on tail bone on sitting, arising from chair

after prolonged sitting, changing position particularly getting in and out of bed, standing, walking and forward flexion movements, defecation and coughing.

SIGNS :-• Patient sits down slowly after shifting weight

from, buttock to her sits with a slumped posture, pain increase on palpation over sacrum coccygeal or coccygeal joint sites.


managementSITTING IN Acute phase discouraged.Use of coccygeal cushion and a lumbar roll while feeding.Side sitting with weight transferred through thighs.Side lying and prone as a position for resting.Ice packs, frequent gluteal contraction, pelvic floor exercises.Laser, US, TENS, useful.Prevent constipation.Avoid forward movements and lifting.


Cramps Calcium deficiency, ischaemia and nerve root pressure, fluid retention together with reduced activity are causes.

Most common site – calf may also occur in feet and thigh.


Management Calf stretches

Knee extension with dorsiflexion.

Massage – deep kneading

Ankle toe exercises.

Supplementary calcium and daily intake of vitamin B1.


Other problems1. Rib ache 2. Chondromalacia patellae3. Restless leg syndrome4. Uterine ligament pain 5. Pain from abdominal adhesion6. Fatigue 7. Insomnia and nightmare8. Morning sickness


Physiotherapy and exercisesPrenatal and postpartum period

AIMS OF P.T.Give confidence to the women in her abilities.Introducing each member of the team and ensure that the women knows whom to go for the advice.Giving advice on her postural control and correction.Teaching the patient the breathing pattern and relaxation technique in order that she may between uterine contraction and thus conserve her energy.


Assess physical help identify any musculoskeletal or neuromuscular problem that could be aggrevated by pregnancy.Advice an continued sports and work and how to fatigue as an important sign of over activityAdvice on back care and lifting. Teach methods for controlling neuromuscular tensions.

Teach positons used for labour.

Teach postnatal exercises.


RISK OF INTENSIVE EXERCISE IN PREGNANCY

Musculoskeletal trauma.

Increase demand on cardiovascular system already altered by pregnancy.

Hypoglycemia may arise.


Contraindication 1. Absolute :-• Cardiovascular disease.• Acute infection• A history of recurrent spontaneous abortion• Multiple pregnancy• Bleeding or ruptured membranes• Severe hypertension• Suspected IUGR or fetal distress • Meternal Diabetes


Contraindication 2. Relative:-• Women unused is high levels of exertion• Blood disorders such as sickle cell disease and

anemia• Thyroid disease• Extreme maternal over weight or under weight• Extreme fatigue• Diastasis recti.


selected exercises techinquePostural exercises1. Stretching 2. Strengthening

Abdominal muscles exercises


Postural exercises

1. Stretching ■ Upper neck extensors■ Scapular protractors , shoulder internal rotators,

and levator scapulae■ Low back extensors■ Hip adductors and hamstring■ Ankle planterflexor


Postural exercises2. Strengthening:

■ Upper neck flexor , lower neck and upper thoracic extensor

■ Scapular retractor and depressors■ Shoulder external rotators ■ Trunk flexors■ Hip extensor■ Knee extensor■ Ankle dorsiflexor


Abdominal muscle exerciseCorrective exercises DRAM■ Head lift■ Head lift with pelvic tilt■ Leg sliding■ Pelvic tilt exercise■ Trunk curls

Resisted posterior pelvic tilt■ Pelvic lifts■ Modified bicycle


Pelvic motion training■ The pelvic clock■ The pelvic clock progression

Pelvic floor awareness training and stregthening■ Contract relax■ Quick contraction ■ Elevator exercise■ hypertonus


Modified UE and LE strengtheningStanding push upsHip extension– Supine bridging – Quadruped leg raising

Modified squatingScapular retraction


PERINEUM & ADDUCTOR FLEXIBILITYSelf stretching


RELAXATION & BREATHING EXRelaxation & Breathing exercise.

Are given with the following objectives1. To obtain rest during pregnancy. 2. To help the mother regain normal health

afterwards by preventing unnecessary fatigue 3. Most common method of relaxation is

MITCHELLS METHOD.4. Patient position in kneeling forward on to one’s

arm on a cushion placed on a seat of a chair.


Contd…5. In this position wt. of the fetus lies on the

anterior abdominal wall & pelvic floor relaxes

6. In this position pt. take deep diaphragmatic breathing.

7. Other methods of relaxation are a. mental imagery.b. . muscle setting – “Jacobson’s

Method”


Unsafe exercise during pregnancyBilateral straight leg raising“Fire hydrant” exerciseAll four (quadruped) hip extensionUnilateral weight bearing activities


Reference Physiotherapy in obs & gynae By Margaret Polden and Jill Mantle

Therapeutic Exercise By Kisner Colbay

Google search for diagrams


Musculoskeletal Problem in Pregnancy

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