1. Women’s Health Overview Implications for Physical Therapy Jane Frahm, PT, BCIA PFMD Rehab Institute of Michigan/WSU

2. All Assessment and Rx needs to respect patient’s diagnosis and activity restrictions. THERAPY RX GOALS:  Maximize strength and joint range with bed mobility / ADLs usually performed supine or sidelying  Stimulate circulation, help prevent DVT  No  Intra-Abdominal Pressure allowed, do not activate abdominals during movement  Counteract physiological effects of bedrest with no increase in IAP

3.  VAGINAL BIRTH  Vaginal delivery after cervix is fully dilated  CAESAREAN BIRTH  Surgical birth through incisions in abdominal wall and uterus

4.  PHYSIOLOGICAL/HORMONAL CHANGES AFFECT REPRODUCTIVE ORGANS  Lower Urinary Tract  Perineum  GI System  Breasts

5. MUSCULOSKELETAL/POSTURAL Target Rehab program for specific area of dysfunction Emphasize Body Mechanics for Child care and ADLs – with special attention to Abdominals / Diastasis Recti Pubic Symphysis / Movement difficulty and pelvic instability Pelvic Floor / Incontinence Lumbo-Pelvic Mechanics / SI Dysfunction

6.  DEFINITION: Widening of the Symphysis pubis on x-ray – (Normal symphysis: about 1/2 cm. -5 mm)  Anything wider, with symptoms, in a pregnant or post partum female, should be treated as a symphysis separation.  May be widening of one or both S-I joints, in addition to widening of the symphysis pubis.  (JAOA, 97:3, March 97, 152-155)

7.  Normally -very stable But even a small degree of hypermobility leads to inflammation and pain  Pubic hypermobility usually accompanied by SI hypermobility /vice versa - check for both  Muscle forces on pelvis - in walking - can be painful, increase hypermobility, and create torque or shear  SI belt is a must  The larger the separation, the easier the delivery usually

8.  Normal – 1 st Degree  Amt of separation: 0 - <0.5 to 0.9 cm (5-9 mm)  Common Symptoms: none  Common Treatment: none

9. 2nd degree - 0.9-2 cm (9- 20 mm) Common Symptoms: Pain in pubes, groin, may also be in SI area Fear of moving Urinary problems Gait changes (if able to walk) No postpartum pooch

10.  3rd degree Amt of separation: >2cm (20 mm)  Common Symptoms:  Same as Moderate Separation  Distinct waddling gait- or inability to walk at all  Urinary Incontinence

11.  Pregnant women 1 st to 3 rd trimesters  Post-Partum women: within 12 - 36 hours of delivery

12.  Influence of pregnancy hormones specifically relaxin on soft tissue. Hormones are responsible for: Uterine growth Stretching of soft tissue Pelvic joint relaxation Renders the pelvic ring unstable at the symphysis The stretching of a vaginal delivery can further contribute to the instability

13.  Other precipitating factors (Intrapartum )  Assisted deliveries, i.e., forceps, vacuum extraction, large baby, shoulder dystocia, 2 persons supporting mother ’ s legs in deep knee – chest during pushing ( Post partum )  Mother suddenly turns or twists, missteps over an elevated sill, e.g., or may create shear forces over the pubes just getting into or out of bed.

14.  Incredible pain over pubis  Sudden inability to walk (patient may have been walking after delivery and suddenly cannot)  Inability to move in the bed  Patient may appear unreasonable  ALL MOVEMENT JUST HURTS

15.  Positioned supine (usually), presents with legs in abducted  Pt presents with mobility that is painful  Patient may be frustrated with pain and apparent lack of understanding of staff  Careful questioning of patient  Observation of patient  Palpation of pubes may not be possible due to pain

16.  Strap pelvis  Abdomino-pelvic binder  Specific pelvic belt (Com-pressor- OPTP or Serola SI belt)  Other Medical Treatments  Inject hydrocortisone,chymotrypsin into symphysis  Bed rest to moderate activity as tolerated

17. SEROLA S-I BELT www.serola.net

18.  Apply external support ABDOMINAL BINDER  Placed low over greater trochanters and fastened over pubes  Placement with pt. supine  Sometimes 2 persons have to slide the support under the patient  Facilitate bed mobility - Observe first, then make suggestions  Patient usually knows how to initiate movement-in the least painful way.

19.  Patient will keep her body in straight planes, - rolling to her side may not be feasible  “Rule of thumb” - think of how a post-op THA patient moves

20.  Standing may be all patient can do on day one- due to inflammation over the pubes  Some require pain or anti-inflammatory meds or both; and bed rest for 12 – 24h

21.  GAIT (Rolling walker required) Often inability to swing-through and heel strike with either extremity  Patient may "slide" or "scoot" the extremity - often painfully slowly

22. All prime L/E movers and stabilizers attach to the pelvis  Movement is slow, but will progress over several days.  Y OU MUST BE PATIENT WITH THESE PATIENTS !  L.O.S. can be increased with this diagnosis.

23.  Pending the hospital system you are employed at:  Share your assessment/ recommendations with medical team  They may NOT be aware of etiology  You may be the one to recommend x-rays

24.  AMBULATORY ASSIST / OTHER EQUIPMENT Ask unit secretary to order an abdominal binder Overhead trapeze ideal, but often not available B.S.C. may be needed- assess after you see patient Rolling walker is needed in all cases

25.  Introduce Lumbar"stabilization” right away:  “Engagement of the obliques and transversus before and during each step will help stabilize the pelvis.  Possible for patient to practice this, even though the abs have major “Stretch” weakness