1. Chapter 15 Prevention and Management of Common Musculoskeletal Injuries Incurred through Exercise during Pregnancy Mimi Zumwalt, MD

2. Learning Objectives Understand the anatomy involved with pregnancy and associated structures affectedUnderstand the anatomy involved with pregnancy and associated structures affected Learn about the physiological/systemic changes of pregnancy and their effects on exercisingLearn about the physiological/systemic changes of pregnancy and their effects on exercising Delineate the anatomic/structural issues affecting types of exercise while pregnantDelineate the anatomic/structural issues affecting types of exercise while pregnant Comprehend different prevention measures and methods of management of pregnant- related musculoskeletal conditionsComprehend different prevention measures and methods of management of pregnant- related musculoskeletal conditions

3. Introduction Pregnant state w/anatomical, structural, physiological, & systemic changesPregnant state w/anatomical, structural, physiological, & systemic changes Hormonal/biochemical; musculoskeletalHormonal/biochemical; musculoskeletal Unique orthopaedic injuries/conditionsUnique orthopaedic injuries/conditions Must protect fetus from physical harmMust protect fetus from physical harm Modify exercises/choose carefullyModify exercises/choose carefully

4. Anatomical & Structural Considerations in the Pregnant Female Involved anatomyInvolved anatomy Uterus in pelvis - ilium/pubis, ischium, & sacrum/coccyx w/pubic symphysis & sacroiliac joints, ligaments, muscles/fasciaUterus in pelvis - ilium/pubis, ischium, & sacrum/coccyx w/pubic symphysis & sacroiliac joints, ligaments, muscles/fascia Mammary glands against thoracic cageMammary glands against thoracic cage Surrounding supporting structuresSurrounding supporting structures Spinal & abdominal musculatureSpinal & abdominal musculature

5. Physiological & Systemic Changes Affecting Exercise in Pregnancy Hormonal chain – HCG  relaxinHormonal chain – HCG  relaxin Estrogen & progesteroneEstrogen & progesterone Prolactin, insulin, cortisol, para/thyroidProlactin, insulin, cortisol, para/thyroid Fetal-maternal metabolismFetal-maternal metabolism Anabolic  ”accelerated starvation”Anabolic  ”accelerated starvation” General/dependent edemaGeneral/dependent edema Inflammatory response/nerve entrapmentInflammatory response/nerve entrapment

6. Anatomical Structures Affecting Exercise Capability in Pregnant Athletes Anterior/inferior center of gravity shiftAnterior/inferior center of gravity shift Roundback/swaybackRoundback/swayback LBP, pelvic girdle & SI joint pain, widened pubic symphysisLBP, pelvic girdle & SI joint pain, widened pubic symphysis XS increased hip & knee joint forcesXS increased hip & knee joint forces Elevated pressure of pelvic floor muscles, tight/short chest, low back, hip, & thigh m, slack in rectus abdominus & glutealsElevated pressure of pelvic floor muscles, tight/short chest, low back, hip, & thigh m, slack in rectus abdominus & gluteals

7. Prevention of Musculoskeletal Injuries in Pregnant Female Athletes LBP, pelvic girdle, pubic symphysis, SI joint pain, PFPS, ankle sprains; leg cramps, diastasis recti, meralgia paresthetica, CTS & other compression neuropathy, de Quervain’sLBP, pelvic girdle, pubic symphysis, SI joint pain, PFPS, ankle sprains; leg cramps, diastasis recti, meralgia paresthetica, CTS & other compression neuropathy, de Quervain’s Beware of potential hip & other sites of osteoporotic fxBeware of potential hip & other sites of osteoporotic fx Core conditioning, spinal stabilization, hip balancing exercises (Swiss Pilates)Core conditioning, spinal stabilization, hip balancing exercises (Swiss Pilates) Avoid xs repetitive usage/loadingAvoid xs repetitive usage/loading

8. Prevention of Musculoskeletal Injuries in Pregnant Female Athletes ACOG/ACSM/CDC exercise guidelinesACOG/ACSM/CDC exercise guidelines 30-45min most days of the week30-45min most days of the week Resistance & endurance trainingResistance & endurance training Avoid prolonged supine position or motionless standing or impact activityAvoid prolonged supine position or motionless standing or impact activity Avoid xs height or deep water or team/ contact & other high risk sportsAvoid xs height or deep water or team/ contact & other high risk sports Avoid Valsalva maneuver w/wt liftingAvoid Valsalva maneuver w/wt lifting Borg’s RPE scaleBorg’s RPE scale

9. Management of Orthopaedic Conditions in Pregnant Athletes Avoidance of aggravating positions/activitiesAvoidance of aggravating positions/activities Physical therapy for postural control, core conditioning, & spinal stabilizationPhysical therapy for postural control, core conditioning, & spinal stabilization Abdominal, low back, pelvic floor, hip/ gluteal strengtheningAbdominal, low back, pelvic floor, hip/ gluteal strengthening Aquatic > ground exercisesAquatic > ground exercises Acupuncture, lumbosacral corsetAcupuncture, lumbosacral corset Limited steroid injections, NO NSAIDs, local modalities or spinal tractionLimited steroid injections, NO NSAIDs, local modalities or spinal traction

10. Conclusion Increased body weight, morphologic & physiologic changes challengingIncreased body weight, morphologic & physiologic changes challenging Working out beneficial for mother & babyWorking out beneficial for mother & baby Modify activities/maneuversModify activities/maneuvers Avoid certain positions/sports/conditionsAvoid certain positions/sports/conditions Minimize injury risk since limited options for orthopaedic treatment of injuriesMinimize injury risk since limited options for orthopaedic treatment of injuries

11. Case Study You are a family practice physician working in a small town where the closest major medical center is a couple of hours away. An emergency room is available near by, but medical resources are scarce. You have been the “family doctor” for a few decades in the community. In fact, you have made “house calls” in the middle of the night to tend to extremely ill patients or to deliver an unexpected baby! Currently you have five different women who are in various stages of pregnancy, three of whom are fairly healthy and all desire an exercise program. One woman, unfortunately, has gestational diabetes along with being extremely overweight. In fact, she has already gained over 60 pounds nearing the end of her second trimester. She has been giving in to her “food cravings” and wants to start exercising to lose as much weight as possible. The second woman just found out she is pregnant and has been working out for several years along with competing in triathlons. She wants to keep up with her training and competitions plus is very afraid of “putting on weight”. The third woman is near the end of the first trimester, is gaining weight appropriately, and has begun a workout program. She needs to know whether she can continue to exercise and when she should stop working out. The fourth mother to be, although she has been involved with a training regimen for a few years, is so afraid that she’ll damage the fetus since it’s her first baby, so she decides that she needs to quit exercising all together. The fifth female patient is complaining of low back spasms and abdominal cramping when she attempts to work out, especially lower extremity exercises but she does not want to slow down.You are a family practice physician working in a small town where the closest major medical center is a couple of hours away. An emergency room is available near by, but medical resources are scarce. You have been the “family doctor” for a few decades in the community. In fact, you have made “house calls” in the middle of the night to tend to extremely ill patients or to deliver an unexpected baby! Currently you have five different women who are in various stages of pregnancy, three of whom are fairly healthy and all desire an exercise program. One woman, unfortunately, has gestational diabetes along with being extremely overweight. In fact, she has already gained over 60 pounds nearing the end of her second trimester. She has been giving in to her “food cravings” and wants to start exercising to lose as much weight as possible. The second woman just found out she is pregnant and has been working out for several years along with competing in triathlons. She wants to keep up with her training and competitions plus is very afraid of “putting on weight”. The third woman is near the end of the first trimester, is gaining weight appropriately, and has begun a workout program. She needs to know whether she can continue to exercise and when she should stop working out. The fourth mother to be, although she has been involved with a training regimen for a few years, is so afraid that she’ll damage the fetus since it’s her first baby, so she decides that she needs to quit exercising all together. The fifth female patient is complaining of low back spasms and abdominal cramping when she attempts to work out, especially lower extremity exercises but she does not want to slow down.