Treating pregnant patients as an orthopedic physical therapist might seem overwhelming at times.
I practice in a private, outpatient orthopedic clinic in a large city. I started treating women’s and pelvic health patients as a student and plan to continue delving into the specialty for the rest of my career. In clinics where there are practicing women’s health physical therapists, pregnant patients are generally placed on the schedule of those PTs who have additional experience in treating them. This is great and it’s a reason why we have this specialty. But the fact of the matter is, most clinics do not have a women’s health or obstetric physical therapist available to see these patients. All orthopedic PTs should be comfortable treating women who are pregnant. We are all capable, and pregnancy is not something that is going away any time soon.
Common Orthopedic Issues For Pregnant Women
Most pregnant women present in the clinic with things you are already an expert at treating: low back pain and pelvic girdle pain. Pelvic girdle pain is the broad term that encompasses the origin of pain being the SI joint or pubic symphysis.
Studies cite that 71% of pregnant women experience low back pain and 67% experience pelvic girdle pain, but only 15-30% of women received treatment when they voiced their concerns to their physician. These are startling numbers. General aches and pains during pregnancy are normal as the body accommodates to the weight gain and growing baby; but severe pain that is functionally debilitating is not normal. As orthopedic physical therapists and movement specialists, we know how to treat these issues and we can do a lot for these women.
You’re going to treat pregnant women the same way you would for a non-pregnant patient presenting with low back pain and pelvic girdle pain with a few modifications. Here are some tips to get more comfortable.
- Be aware of positioning during your exam and treatment.
It is okay for pregnant women to lie supine. According to the most recent ACOG guidelines, only 10-20% of women will experience symptoms while lying supine, and those symptoms will come on within 3-10 minutes. It is okay to have your pregnant patients like supine so you can perform your examination tests and administer treatment. If they become symptomatic, have them lie on their side until symptoms subside and then resume supine if you need to. Understand that most women, especially in their later trimesters, will be more comfortable in a sidelying or semi-reclined position for treatment and exercise. If you have a plinth that elevates, flip the long side up. You can also use a wedge or pillows.
2. You can absolutely perform manual techniques on pregnant women.
Use your best clinical judgement and remember that pregnant women have increased levels of relaxin circulating, which causes increased joint laxity. So - you probably won’t need to be doing a ton of manipulations. However, these women are in pain and we know that manual therapy techniques can reduce pain. Choose gentle and effective techniques that are focused on relieving muscle tension and spasm.
3. These women need core strengthening.
Pregnant women’s bodies are constantly shifting to accommodate the growing baby. This places them in more of a lumbar lordosis and anterior pelvic tilt (https://www.ncbi.nlm.nih.gov/pubmed/18075592). Give them exercises that help mobilize the low back and decrease the compression in their spine. I spend a lot of time teaching my patients how to perform belly breathing and contract their TA on the exhale. It is easy to see a TA contraction on pregnant women. Cue them to “hug the baby” and watch their belly draw in. Pair that with some gentle core exercises in supine, semi-reclined, or quadruped or sitting. Varying the positions that a pregnant patient exercises in is good to help prepare them for an active labor.
4. Look at their transfers.
Women with pelvic girdle pain especially have difficulty getting in and out of bed. Teach them how to log roll and brace their abdominals with their movement. Look at how they are standing up from a chair. Look at their squat. I include squats on every pregnant and postpartum women’s home exercise program from day one because it is functional and they will be squatting often for childcare tasks.
5. Review body mechanics.
If your patient is already a mom, review how they are picking up their little one(s), putting babies in the car seat, the crib, high chair, etc. These things are going to make a huge difference in their quality of life because these are things they are doing all day long.
6. Check for doming and diastasis recti.
Diastasis recti is when the linea alba becomes stretched beyond its normal width. It is common in pregnancy. One study states that 100% of women will have a diastasis in their third trimester, but the evidence is scattered. Watch for doming with any of the exercises you are prescribing where the belly is looking more like a dome (pouching out in the middle) than round and smooth. That means there is too much pressure on the abdominal wall. Try to modify the exercise or find something different. Don’t be afraid to politely ask your patient to expose their abdomen so that you can see, as long as there is privacy. A lot of PTs feel uncomfortable with this, but remember that your patient is going to be SO thankful that you are checking everything and making sure their exercises are safe and right for them.
7. When in doubt, use an SI belt.
For women with pelvic girdle pain, these belts are a game changer. The belt gives that extra compression and support to the pelvis that the patient is not getting due to weak muscles and ligament laxity in the pelvic girdle. This helps your patient be more independent and feel better with her functional activities. You can recommend that she wear it with exercise too if you feel that she needs that extra support to achieve proper muscle activation. If they are earlier along in pregnancy, size up.
8. Pregnant women are strong.
They can squat, they can deadlift, they can lift weights, they can participate in cardiovascular exercise. According to the ACOG guidelines women who were moderately active prior to pregnancy can continue with moderate physical activity. Women who were light exercises or did not exercise can continue with light physical activity during exercise. You will get patients who did not exercise prior to pregnancy, and you will also have patients who were running marathons.
As long as she is comfortable and not exhibiting any warning signs during physical activity, then it is okay for her to continue the normal routine. Familiarize yourself with the ACOG guidelines for physical activity and educate your patients on contraindications to exercise and warning signs to discontinue exercise. Overall, encourage them to remain physically active at whatever level they are able.
9. Screen for pelvic floor dysfunction with everybody.
It is a simple question, “do you leak urine with running, jumping, coughing, sneezing, or laughing?” If you don’t ask, then you won’t know. Most women will not just offer up the information because they probably don’t know it is something that can be treated.
So, when do you need to refer to a pelvic health PT? If they answer YES to your screening question regarding stress urinary incontinence, refer out. This can be treated. You don’t have to “give your patient away” to a pelvic health PT, but ensure that they get on track to see someone for a consultation. Another reason would be if your patient is complaining specifically of pelvic pain in the pubic symphysis, SIJ or tailbone and you don’t feel like what you are doing is making a difference, then refer out. The pelvic floor muscles attach to each of these structures and they might need more specific and isolated treatment of the pelvic floor.
The fourth trimester is a hot topic right now and I am hoping that means we will be seeing a lot more women, both postpartum and pregnant, come through our doors. If you have a patient who is postpartum, you should screen for any pelvic floor dysfunction including leakage and pelvic pain. Remember the screening question above? Make that a part of your initial intake and then refer your patient to a pelvic health physical therapist if needed. There is a lot to consider with ramping up physical activity level in the postpartum period, but for simplicity, just encourage them to go slow.
Keep It Simple
These pregnant women are either going to be brand new moms or they already have little ones at home. We’re all busy… but moms are especially busy. Keep their home program simple, effective, functional and emphasize consistency. I tend to keep this around 5-8 exercises and prioritize them in order of importance. Also, take into consideration if they are already participating in regular physical activity such as prenatal yoga or exercise classes. Build your program around what they are already doing and how they can supplement their usual routine.
I hope this helps you become more comfortable with treating pregnant women in the ortho setting. They are coming into the clinic with the most common things we see as ortho PTs. It just takes a little bit of modifying your examination and treatment skills and thinking about how to optimize their function for this new role they are about to take.