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What if there was a pill that provided all these benefits…

PREGNANCY AND POSTPARTUM

EXERCISE MYTHS AND FACTS

Exercise during Pregnancy: A History

■ 1950’s: avoid “violent” activities; stick to “gentle” activities like housework and easy walking

■ 1960’s: the standard begins to unravel■ 1970’s: studies published showing benefits of exercise during

pregnancy■ 1980’s: more science, more questions■ 1990’s: evidence-based guidelines…with some holes

■ 2000’s: still some gaps and contraindications in the literature■ 2010’s: continued support for exercise during pregnancy – and more

emphasis on risks of NOT exercising

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Current Pregnancy Exercise Guidelines:

■Vague

■GeneralAnd

Pregnancy Myth #1:

vI shouldn’t start a new exercise program when I’m pregnant.

Women who BEGAN exercise programs while pregnant: § Improved aerobic fitness and muscular strength, had

comparable size infants, significantly fewer cesarean deliveries, and faster postpartum recovery. (Price et al, 2012)

§ Had no difference in birth weight or length of gestation (Haakstad & Bo, 2011)

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Pregnancy Myth #2:

vI should keep my heart rate under 140 BPM.

Heart rate and pregnancy

■ There is an increase in resting heart rate by 10-15 beats per minute in pregnant women. (Avery et al, 2001)

■ Response of sympathetic system to strenuous exercise canbe blunted. (Avery et al, 2001)

■ Relationship between heart rate and oxygen consumption altered during pregnancy. (Pivarnik et al, 2002)

ACOG GuidelinesThe 15-Grade Scale for Ratings of Perceived Exertion ^

■ 67 Very, very light 89 Very light1011 Fairly light1213 Somewhat hard 1415 Hard1617 Very hard1819 Very, very hard 20

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Pregnancy Myth #3:

vLifting weights is dangerous while pregnant; I should stick to walking and prenatal yoga.

ACOG GuidelinesExamples of Safe and Unsafe Physical Activities During Pregnancy*^ ■ The following activities are safe to initiate or continue*:

■ Walking ■ Swimming ■ Stationary cycling ■ Low-impact aerobics ■ Yoga, modified†

■ Pilates, modified ■ Running or jogging‡

■ Racquet sports‡ §

■ Strength training‡

The following activities should be avoided: – Contact sports (eg, ice hockey, boxing, soccer, and basketball) – Activities with a high risk of falling (eg, downhill snow skiing, water skiing, surfing, off-road

cycling, gymnas-tics, and horseback riding) – Scuba diving – Sky diving – “Hot yoga” or “hot Pilates”

Current Research?

■ Ravanelli N, Casasola W, English T, et al. Heat stress and fetal risk. Environmental limits for exercise and passive heat stress during pregnancy: a systematic review with best evidence synthesis. Br J Sports Med Published Online First: 01 March 2018. doi: 10.1136/bjsports-2017-097914

■ Pregnant women can safely do up to 35 minutes of high-intensity aerobic exercise (at 80 to 90 percent of their maximum heart rate) at air temp of up to 77 degrees F and a relative humidity of 45 percent.

■ Can safely do aquatic aerobics in water temps ranging from 83.8-92.1 degrees F for up to 45 minutes.

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ACOG GuidelinesAbsolute Contraindications to Aerobic Exercise During Pregnancy^

■ Hemodynamically significant heart disease

■ Restrictive lung disease

■ Incompetent cervix or cerclage

■ Multiple gestation at risk of premature labor

■ Persistent second- or third-trimester bleeding

■ Placenta previa after 26 weeks of gestation

■ Premature labor during the current pregnancy

■ Ruptured membranes

■ Preeclampsia or pregnancy-induced hypertension

■ Severe anemia

ACOG GuidelinesRelative Contraindications to Aerobic Exercise During Pregnancy^

■ Anemia ■ Unevaluated maternal cardiac arrhythmia ■ Chronic bronchitis ■ Poorly controlled type 1 diabetes ■ Extreme morbid obesity ■ Extreme underweight (BMI less than 12) ■ History of extremely sedentary lifestyle ■ Intrauterine growth restriction in current pregnancy ■ Poorly controlled hypertension ■ Orthopedic limitations ■ Poorly controlled seizure disorder ■ Poorly controlled hyperthyroidism ■ Heavy smoker

ACOG GuidelinesWarning Signs to Discontinue Exercise While Pregnant^

■ Vaginal bleeding

■ Regular painful contractions

■ Amniotic fluid leakage

■ Dyspnea before exertion

■ Dizziness

■ Headache

■ Chest pain

■ Muscle weakness affecting balance

■ Calf pain or swelling

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Pregnancy Myth #4: Exercising will make my pregnancy symptoms worse.

■ Exercise during pregnancy can reduce low back pain. (Garshasbi & Faghih Zadeh, 2005; Shiri et al, 2018)

■ Exercise may help reduce presence of diastasis rectus abdominus (abdominal separation) (Chiarello et al, 2005; Benjamin et al, 2014)

■ Exercise is associated with reduced risk of pelvic girdle pain (Andersen et al, 2015)

Pregnancy Myth #5:

■ If I run throughout my pregnancy, I will “bounce back” more quickly.

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rcog.org.ukPatients > Patient information leaflets > Physical activity and pregnancy

Postpartum Exercise Myths and Facts

Postpartum Myth #1:

■ I can safely resume all exercise after my 6 week check up.

OR■ I can run immediately postpartum because I’m

a runner.

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What does the research say about postpartum return to exercise?

Postpartum physiological changes –abdominal wall■ Diastasis rectus abdominus (DRA) present in 100% of women in

late stages of pregnancy (measured via diagnostic ultrasound) (da Mota et al, 2015)

■ DRA present in 60% of women at 6 weeks postpartum, 45% at 6 months, and 33% at 12 months (Sperstad et al, 2015)

■ The rectus abdominus starts to thicken and the inter-rectus distance decreases after 2 months, but does not return to control values at 12 months postpartum (Coldron et al, 2008)

Postpartum physiological changes –pelvic floor■ Rectal branch of the pudendal nerve stretches up to 35% (Lien

et al, 2005)■ Increased latency in pudendal nerve in women with vaginal

delivery or those who had a c-section after laboring – 12 of 22 women at 6 weeks postpartum and 4 of 22 at 6 months postpartum (Sultan et al, 1994)

■ Less than half (33-40%) of women achieve a normal, atraumatic vaginal delivery (Caldwell-Hall et al, 2018)

■ 64% of women have at least 1 “bothersome” symptom of pelvic floor dysfunction 1 year after their first delivery (Lipschetz et al, 2015)

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Postpartum physiological changes –muscle activation■ Decrease in trunk flexor strength and endurance at 8 weeks and

26 weeks postpartum (Deering et al, 2018)

■ 57% of women in immediate post-partum setting perform pelvic floor contractions (Kegels) incorrectly (Neels et al, 2018)

■ Women with DRA have significant decrease in trunk rotation strength and more difficulty performing a sit up (Hills et al, 2018)

Postpartum Myth #2:

■ I shouldn’t do ANY exercise until after my 6 week check up.

Current postpartum exercise guidelines:

§ “Greater clarity in guidelines would be more useful to both practitioners and the women they serve.” (Evenson et al, 2014)

§ Postpartum exercise linked to improved mood/decreased anxiety and depression, improved cardiorespiratory fitness, and weight control/loss. (Evenson et al, 2014)

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Postpartum Exercise Truth: Women will be ready to return to exercise within avariable time frame at a variable intensity

Postpartum Myth #3:

■ I had a C-section so my pelvic floor is totally fine.

v Pregnancy is associated with bladder neck lowering, increased bladder neck mobility, pelvic organ descent, decreased levator ani strength, and decreased urethral resistance (Van Geelen et al, 2018)

Postpartum Myth #4:

It’s normal to:■ leak urine when I exercise/cough/sneeze.■ Have painful sex■ Continue to have back pain

I just had a baby – I can expect certain symptoms.

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Practical advice to new moms:

1. Start where you left off2. Increase gradually over time – 10% increase per week in intensity OR

duration3. The best exercise is what you enjoy4. No exercise is a BAD exercise, IF it can be done without pain or

symptoms5. Consider symptoms a CALL TO ACTION

6. Request pelvic floor physical therapy – especially if you have lingering symptoms of back or pelvic pain, incontinence, pelvic heaviness/prolapse, or pain with intercourse

Pelvic Floor PT locators:

■ http://pt.womenshealthapta.org

■ https://pelvicrehab.com

■ https://pelvicguru.com/2016/02/13/find-a-pelvic-health-professional/

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Angie Robertson, PT, DPT, OCSabr.dpt@gmail.comwww.inbalance-pt.com

Andersen, L. K., Backhausen, M., Hegaard, H. K., & Juhl, M. (2015). Physical exercise and pelvic girdle pain in pregnancy: A nested case–control study within the Danish National Birth Cohort. Sexual & Reproductive Healthcare, 6(4), 198-203.

Avery, N. D., Wolfe, L. A., Amara, C. E., Davies, G. A. L., & McGrath, M. J. (2001). Effects of human pregnancy on cardiac autonomic function above and below the ventilatory threshold. Journal of Applied Physiology, 90(1), 321-328.

Bahls, M., Sheldon, R. D., Taheripour, P., Clifford, K. A., Foust, K. B., Breslin, E. D., ... & Newcomer, S. C. (2014). Mother's exercise during pregnancy programmes vasomotor function in adult offspring. Experimental physiology, 99(1), 205-219.

Benjamin, D. R., Van de Water, A. T. M., & Peiris, C. L. (2014). Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy, 100(1), 1-8.

Caudwell-Hall, J., Atan, I. K., Rojas, R. G., Langer, S., Shek, K. L., & Dietz, H. P. (2018). Atraumatic Normal Vaginal Delivery: How many women get what they want?. American journal of obstetrics and gynecology.

Chiarello, C. M., Falzone, L. A., McCaslin, K. E., Patel, M. N., & Ulery, K. R. (2005). The effects of an exercise program on diastasis recti abdominis in pregnant women. Journal of Women’s Health Physical Therapy, 29(1), 11-16.

Coldron, Y., Stokes, M. J., Newham, D. J., & Cook, K. (2008). Postpartum characteristics of rectus abdominis on ultrasound imaging. Manual therapy, 13(2), 112-121.

da Mota, P. G. F., Pascoal, A. G. B. A., Carita, A. I. A. D., & Bø, K. (2015). Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual therapy, 20(1), 200-205.

Deering, R. E., Cruz, M., Senefeld, J. W., Pashibin, T., Eickmeyer, S., & Hunter, S. K. (2018). Impaired Trunk Flexor Strength, Fatigability, and Steadiness in Postpartum Women. Medicine and science in sports and exercise.

Ekholm, E. M., & Erkkola, R. U. (1996). Autonomic cardiovascular control in pregnancy. European Journal of Obstetrics and Gynecology and Reproductive Biology, 64(1), 29-36.

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Evenson, K. R., Mottola, M. F., Owe, K. M., Rousham, E. K., & Brown, W. J. (2014). Summary of international guidelines for physical activity following pregnancy. Obstetrical & gynecological survey, 69(7), 407.

Garshasbi, A., & Faghih Zadeh, S. (2005). The effect of exercise on the intensity of low back pain in pregnant women. International Journal of Gynecology & Obstetrics, 88(3), 271-275.

Haakstad, L. A., & Bø, K. (2011). Exercise in pregnant women and birth weight: a randomized controlled trial. BMC pregnancy and childbirth, 11(1), 66.

Hills, N. F., Graham, R. B., & McLean, L. (2018). Comparison of Trunk Muscle Function Between Women With and Without Diastasis Recti Abdominis at 1 Year Postpartum. Physical therapy.

Kuhrt, K., Harmon, M., Hezelgrave, N. L., Seed, P. T., & Shennan, A. H. (2018). Is recreational running associated with earlier delivery and lower birth weight in women who continue to run during pregnancy? An international retrospective cohort study of running habits of 1293 female runners during pregnancy. BMJ open sport & exercise medicine, 4(1), e000296.

Labonte-Lemoyne, E., Curnier, D., & Ellemberg, D. (2017). Exercise during pregnancy enhances cerebral maturation in the newborn: A randomized controlled trial. Journal of clinical and experimental neuropsychology, 39(4), 347-354.

Lien, K. C., Morgan, D. M., Delancey, J. O., & Ashton-Miller, J. A. (2005). Pudendal nerve stretch during vaginal birth: a 3D computer simulation. American journal of obstetrics and gynecology, 192(5), 1669-1676.

Lipschuetz, M., Cohen, S. M., Liebergall-Wischnitzer, M., Zbedat, K., Hochner-Celnikier, D., Lavy, Y., & Yagel, S. (2015). Degree of bother from pelvic floor dysfunction in women one year after first delivery. European Journal of Obstetrics & Gynecology and Reproductive Biology, 191, 90-94.

Neels, H., De Wachter, S., Wyndaele, J. J., Van Aggelpoel, T., & Vermandel, A. (2018). Common errors made in attempt to contract the pelvic floor muscles in women early after delivery: A prospective observational study. European Journal of Obstetrics & Gynecology and Reproductive Biology, 220, 113-117.

Pennick, V., & Liddle, S. D. (2013). Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database of Systematic Reviews, (CD0011), 1-100.

Pivarnik, J. M., Stein, A. D., & Rivera, J. M. (2002). Effect of pregnancy on heart rate/oxygen consumption calibration curves. Medicine and science in sports and exercise, 34(5), 750-755.

Price, B. B., Amini, S. B., & Kappeler, K. (2012). Exercise in pregnancy: effect on fitness and obstetric outcomes—a randomized trial. Medicine & Science in Sports & Exercise, 44(12), 2263-2269.

Shiri, R., Coggon, D., & Falah-Hassani, K. (2018). Exercise for the prevention of low back and pelvic girdle pain in pregnancy: A meta-analysis of randomized controlled trials. European Journal of Pain, 22(1), 19-27.

Sperstad, J. B., Tennfjord, M. K., Hilde, G., Ellström-Engh, M., & Bø, K. (2016). Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med, bjsports-2016.

Sultan, A. H., Kamm, M. A. and Hudson, C. N. (1994), Pudendal nerve damage during labour: prospective study before and after childbirth. BJOG: An International Journal of Obstetrics & Gynaecology, 101: 22-28. doi:10.1111/j.1471-0528.1994.tb13005.x

Ravanelli, N., Casasola, W., English, T., Edwards, K. M., & Jay, O. (2018). Heat stress and fetal risk. Environmental limits for exercise and passive heat stress during pregnancy: a systematic review with best evidence synthesis. Br J Sports Med, bjsports-2017.

Van Geelen, H., Ostergard, D., & Sand, P. (2018). A review of the impact of pregnancy and childbirth on pelvic floor function as assessed by objective measurement techniques. International urogynecology journal, 1-12.