Injury & Rehab: avoid lower back and pelvic injuries in pregnant clients
By training your pregnant client to maintain physical fitness you can help her avoid injury and increase the likelihood of a good birthing experience.
Many physical changes occur during pregnancy in order to prepare the body for giving birth. When training a woman during her pregnancy, it is important to understand how these changes affect her, so that you can help her avoid sustaining common injuries and musculoskeletal problems. These include lower back pain, sacroiliac pain, pubic symphysis dysfunctions and pelvic floor dysfunction, among many others.
Significant physiological changes experienced during pregnancy include increased cardiorespiratory capacity, and musculoskeletal, hormonal and other physiological adaptations. Hormonal changes during pregnancy cause increased mobility of the joints, which can often result in lower back or sacroiliac pain. Balance may be affected by changes in posture (Butler et al. 2006), which can increase risk of falling. A reduction in muscle strength and tone has also been documented. All of the above can affect physical performance and increase the likelihood of musculoskeletal injuries.
Aims of exercise during pregnancy
There are three main aims when it comes to training a pregnant client:
1. Maintain fitness, health and optimal weight
2. Maintain or improve core strength (including pelvic floor)
3. Reduce musculoskeletal pain and problems.
The primary goal throughout pregnancy is to maintain physical fitness, not to increase it and lose weight. Exercise contributes to keeping the body weight within reasonable limits, which is important for the woman and the foetus. It is important to let your client know that her fitness will not improve while she is pregnant. Rather, let her know that the aim of her training program will be to prevent common musculoskeletal problems and improve her likelihood of having a good birthing experience.
The forms of physical activity that are recommended for cardiovascular fitness include dynamic exertion using major muscle groups, such as brisk walking, swimming, aqua aerobics, cycling and rowing (Artal et al. 2003).
The recommended dose of exercise for a woman during pregnancy is three to five times per week for at least 30 minutes at moderate intensity (betterhealth.vic.gov.au). Moderate exercise is deﬁned as exercise or any activity that is equivalent in difﬁculty to brisk walking.
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Strengthen for prevention
Strength is key to injury prevention during pregnancy. By assisting your client to strengthen her core and global muscle systems she will benefit from enhanced support of the lumbar spine and pelvis.
Due to the laxity of the ligaments and the reduction in muscle tone during pregnancy, exercises that activate the pelvic floor and the core without increasing intra–abdominal pressure are very beneficial. Pelvic ﬂoor muscle training during pregnancy has been found to improve muscular control, reduce lower back pain and prevent urinary incontinence during pregnancy and after childbirth. Pelaez et al. (2013) found that women who performed a structured pelvic floor program three times per week experienced reduced leakage during pregnancy compared to a control group.
Pilates is a great form of exercise for pregnant clients because it is low impact, emphasises posture and body alignment and can reduce the risk or severity of incontinence through facilitating pelvic floor muscles.
Global muscle strengthening
Once the core is functioning optimally, the next goal should be to strengthen the global muscle systems to provide support to the lumbar spine and pelvis during this vulnerable time. This can be done with exercises which integrate the muscle sling systems, which are groups of muscles that work together to provide stability across the pelvis.
The anterior oblique muscle system (AOS) spans across the front of the pelvis and is an important stabiliser of the lumbar spine and pubic symphysis. The AOS incorporates the adductor muscle and the contralateral oblique muscles. Exercises that work the anterior oblique system include:
- Sitting on Swiss ball with knee lift
- Standing woodchop with knee ball squeeze.
The other important global muscle subsystem is the posterior oblique system (POS). The muscles that comprise the POS are the largest in the body – the latissimus dorsi and the contralateral gluteus maximus muscles. These muscles work together to exert forces on the body that compress and stabilise the sacroiliac joints and hence the pelvic girdle.
These muscle systems also stabilise the lumbar spine and enhance the transference of force across the body (proximally to distally). Exercises which integrate the POS system include:
- Squat to row/lat pull down
- Bridges on Swiss ball with lat pull down using banding.
The most commonly prescribed combinations of sets and repetitions for strength training that have been recommended for pregnant women are 12 –15 repetitions in two to three sets (Penny, 2008).
Avoiding injury when training pregnant clients
- Heavy weight training and contact sports, or anything with high risk of falling over, should be avoided (Kader et al. 2014)
- Avoid prescribing any exercises that increase intra-abdominal pressure and breath holding (e.g. crunches!)
- Advise your client to avoid lying supine after four months of pregnancy
- Keep exercises low impact
- Avoid activity that requires rapid changes of position, because blood pressure drops in the second trimester
- Encourage your client to have a carbohydrate snack 1 to 2 hours before exercising, because pregnant women use carbohydrates at a greater rate during exercise.
Although precautions need to be taken, there are a number of evidence-based recommendations advising that all pregnant women without medical risk can achieve great health benefits through physical activity. Certain forms of cardiovascular exercise, and specific conditioning work for the lower back and pelvis to maintain strength and stability, can help reduce common musculoskeletal injuries.
Jenny Doyle, BSc (Hons), MSc, MCSP, MAPA is a physiotherapist, sports scientist and clinical Pilates instructor with extensive clinical experience. She works with Active Anatomy Physiotherapy which runs health professional rehabilitation workshops across Australia. activeanatomy.com and 02 9451 9014.