Gymnastics: Exercise Physiology in the Management of Lumbar Stress Fractures

by Sami Gurdon

 

Today’s article is going to examine one of the most common and also one of the most preventable injuries we see in Gymnastics – the Lumbar Stress fracture. Gymnasts are at an increased risk of developing lumbar stress fractures due to the excessive volume of lumbar extension and rotation coupled with the repetitive nature of the sport and high volume of training required.

START Training client and National Team Member Heath Thorpe

Recovery Prospects

In most cases it is possible to fully recover and build back to full training after an initial period of rest and no impact. This does however require careful management of the athlete including assessing and rectifying any underlying muscle imbalances or movement patterning issues that lead to the injury in the first place. Furthermore, they must adhere to an adequate period of rest and no impact before beginning a slow and progressive return to impact and full training. In some cases it may also be necessary to modify any pre injury skills and routines that may increase their risk of re-injury due to excessive lumbar hyperextension required or poor technique by the gymnast.

Initial Treatment

After imaging and diagnosis, physiotherapy is always the first port of call for any athlete with a stress fracture. Through manual treatment physios will work to reduce pain levels and minimise risk of further exacerbation of the condition. They will often commence basic intrinsic core retraining early in the treatment and will aim to restore pain free range of motion.

The Return to Training Process

After an initial period of rest and manual treatment the gymnast is cleared to start re-strengthening in preparation for the return to training process. This is ideally where exercise physiologists work with the athlete to get them to a point where their coach can safely and confidently begin a progressive build back to full training.

Assessing the athlete:

To give the athlete the best chance of returning to training with a low reinjury risk it’s crucial to identify why the injury occurred in the first place. An Exercise Physiologist must perform a biomechanical assessment and analyse the training program that was in place leading up to the injury as this can give some really important cues as to how and why the injury occurred. It’s important also to review the athletes skill set as if we combine this information with what was found in the movement assessment we can identify skills that might need slight tweaking or re-training and this is where communication with the coach becomes really important to ensure the best outcome for the athlete.

There are a couple of really common postural problems that are quite specific to gymnasts that result in joint instability, muscle imbalances and poor landing mechanics. These issues can be responsible for many of the stress fractures and other common overuse syndromes seen in the sport. It’s important however to treat everyone as an individual and ensure that we don’t adopt a one size fits all approach as there are many other possible causes that could be easily missed.

Rehabilitation Process: 

Following a biomechanical assessment the gymnast will commence a staged restrengthening program. This will be slightly different for each gymnast depending on the specific factors that led to their injury but a basic outline has been provided below:

 

STAGE 1: 

  • Core: Intrinsic core retraining in static and/or isometric positions
  • Pelvis: Basic pelvic awareness exercises and basic pelvic mobility
  • Lower Body: Basic proprioception exercises only
  • Flexibility: Auxiliary stretching and mobility work that places minimal strain on the lower back.

 

STAGE 2: 

  • Core: Advanced transverse abdominus and intrinisic core exercises (increasing complexity from stage 1), lower abdominal activation exercises and isometric oblique strengthening
  • Lower Body Strength: Low impact muscle activation and re-engagement exercises of posterior chain muscles (hamstrings, glutes etc) and lower limb stabilising muscles (bodyweight only and mostly static)
  • Flexibility: as per stage one with the addition of upper body stretches and trigger work (with the consideration of minimising strain on the lumbar spine).
  • Pelvic Mobility: more advanced pelvic awareness and mobility exercises
  • Cardio: Light work on stationary bike
  • Gymnastics: Advised to complete rehabilitation program in the gym with reduced training hours in order to keep routine and avoid isolation.

 

STAGE 3: 

  • Core: Focus on building core endurance and introducing rotational and anti-rotational core control
  • Lower Body Strength: more advanced stability exercises, re-introduction of more compound and complex dynamic strength exercises with a focus on correcting pelvic position, preparation for reintroduction of landing mechanics.
  • Upper Body Strength: Address any shoulder stability or scap setting deficits, re-introduce basic upper body strength ensuring a neutral pelvis is maintained.
  • Flexibility: continue to progress stretching and mobility work avoiding positions that strain the lower back or place the gymnast in lordotic postures
  • Cardio: Light to moderate stationary bike or deep water running.
  • Gymnastics: Can introduce some basic gymnastics specific low impact work such as ankle complex work on beam and small amounts of static handstand hold work.

 

STAGE 4: 

 

  • Core: Continue to progress elements of previous phase as well as introducing more advanced dynamic core control progressions.
  • Lower Body: strengthen through full ranges of motion, improve single leg stability and introduce basic landing mechanics.
  • Upper Body: Continue as per last phase progressing to more advanced exercises that are isolative to the upper body.
  • Flexibility: Continue as per last phase with introduction of controlled lumbar extension mobility
  • Cardio: Moderate intensity on exercise bike or elliptical, introduction of low impact jogging and jumping in water (immersed to chest height)
  • Gymnastics: work with coach to reintroduce gymnast to basic training progressions (mostly non dynamic skills).

 

STAGE 5: 

 

  • Core: Continue progressions as per last phase with the gradual reintroduction of gymnastics specific exercises
  • Lower Body: Progress to advanced landing mechanics, introduce multi-directional landings and retrain jumping and take-off mechanics
  • Upper Body: Continue progressions as per last phase with the gradual reintroduction of gymnastics specific exercises and whole body exercises
  • Flexibility: Continue as per last phase with reintroduction of former stretching regime.
  • Gymnastics: work with coach to reintroduce basic training progressions (begin work on appropriate dynamic basic skills.
  • Cardio: Moderate intensity and introduction of higher intensity intervals on exercise bike.

 

STAGE 6:

  • Continue on with maintenance program
  • Begin progressive return to full training load.
  • Modification of skill set if necessary to decrease risk of re-injury.

Summary: 

While we can’t completely reduce the risk of one occurring due to the nature of the sport and high volume of training required we can greatly reduce the risk of injury or re-injury. By developing control through full range of movement, correcting muscle imbalances particularly anterior to posterior muscle imbalances at the pelvis, improving core control and strengthening a gymnast to optimise landing mechanics we can greatly increase outcomes for gymnasts recovering from lumbar stress fractures.

If you would like to know more or need help recovering from injury please contact Sami for more information on (07) 3356 9119 or 0408 806 209

 

START TRAINING client Heath Thorpe

Training Considerations During Pregnancy Part VI: Exercises for Pregnant Woman

Abdominal Muscles

During pregnancy, it is important to check for advanced separation of the abdominal muscles in order to take precautions to avoid any further separation.

The abdominal muscle in the centre is divided by a seam, so the muscle is really two halves.

The hormones present during pregnancy cause this seam to soften and stretch as the abdominal muscles accommodate the growing baby. If the seam stretches enough, a separation of the abdominal muscle may occur.

A separation can happen gradually or as a result of sudden exertion if the abdominal area is weak. A pregnant woman may be unaware of the separation as it causes no direct pain. However, she might have increased backache, as the abdominal muscles are needed to control a pelvic tilt and maintain proper posture.

 

If any separation is found, avoid further separation by:

  • Doing mild abdominal strengthening while the client crosses her hands over her abdominal area to support and bring the muscles together.
  • Ensure client exhales as she lifts her head; this decreases pressure in the abdomen and allows abdominal muscles to work more efficiently.
  • Avoid abdominal bulging by making client conscious of contracting her abdominal muscles when lifting and avoid straining of any kind.

 

Pelvic Tilt

This exercise is very important because it is the building block of good posture and strengthens abdominal and back muscles. This therefore decreases back strain and fatigue. Practice it often.

  1. Client to lie on back with knees bent.
  1. Inhale through the nose and tighten stomach and buttock muscles.
  1. Flatten the small of the back against the floor and allow the pelvis to tilt upward.
  1. Hold for a count of five as the client exhales slowly.
  1. Relax, repeat.

Other positions in which you can perform the pelvic tilt are while on your hands and knees or while standing upright.

 

* CAUTION: Ensure client DOES NOT arch back, bulge abdomen or push with feet to obtain this motion.

 

Sit-ups

There are two variations of sit-ups:

 

Forward Sit-Up

  1. Have client lie on her back with knees bent and breathe in slowly through the nose.
  1. Have the client breathe out through partially pursed lips as she raises her head, hands pointing to the knees or placed behind the head.
  1. Have client tuck her chin toward her chest and lift her shoulders off the floor (not more than 45 degrees).

 

Diagonal Sit-Up

  1. Have client lie on her back with knees bent and breathe in slowly through the nose.
  1. Have her point her right hand toward her left knee while raising her head and right shoulder. Breathe out slowly through the mouth. Keep the left knee bent slightly and the heel on the floor.

Note: using a bosu ball or other roller in the base of the back allows upper sit ups to activate lower abs while supporting the lower back to prevent disc injury

 

Kegels

Kegel exercises tone the pubococcygeal (PC) muscle. This is the muscle you use to stop and start the flow of urine. Exercising this muscle helps prevent haemorrhoids, supports the growing baby and assists during and after labor.

 

Clients can learn to isolate this muscle by stopping the flow of urine a few times. Use this technique only to locate the muscle. Don’t exercise the muscle this way as it may lead to a urinary tract infection.

  1. Instruct the client to squeeze the PC muscle for five seconds; relax for five seconds, then squeeze again.
  1. At first, do 10 five-second squeezes three times a day. Work up to doing 100 Kegels each day.

Variation: Flutter exercises – squeeze and release, then squeeze and release as quickly as you can.

 

Arm/Upper Back Stretch (Flying Arm Exercise)

  1. Raise your arms over your head, keep your elbows straight and the palms of your hands facing one another. Hold for at least 20 seconds.
  1. Lower your arms out to your side. Keep your upper back straight.
  1. Bring the backs of your hands together as far as possible behind your back and stretch.
  1. Repeat 5 times.

 

Squatting

  1. Move to the squatting position, knees over toes.
  1. Keep heels on the floor; feel the stretch in the back of thighs.
  1. Hold for 20-30 seconds. Gradually increase the time to 60-90 seconds.
  1. Relax the head and arms throughout this exercise.

 

This is a good exercise to prepare for squatting during the pushing stage of labour.

 

Calf Stretch

  1. Lean against a wall or firm surface.
  1. Reach one leg out behind, keeping the heel on the floor.
  1. Lean into the wall to increase the stretch of the calf.
  1. Hold for 20-30 seconds.
  1. Repeat with each leg.

 

This is a good exercise for the client to do before going to bed if she is bothered by leg cramps at night.

Training Considerations During Pregnancy Part V: Exercise Selection Considerations

Exercise Programming and Pregnancy

Selecting the correct sports exercises while pregnant is crucial. All programs designed for pregnant women should include low impact aerobic activities to increase cardiovascular and vascular density development. These aerobic exercises will increase stroke volume and haemoglobin concentrations.

It is important to avoid near maximal activities as they may restrict blood flow to the foetus and thus can cause foetal distress. Maximal activities may also magnify the mother’s feelings of fatigue, as her energy supply is unable to match demand.

Trainers should avoid using recumbent bikes, as this may cause the foetus to push on the inferior vena cava. This pressure on the inferior vena cava can restrict venous return of de-oxygenated blood and thus increase oxygen demand by the muscles as the strain to sustain activity. As a result, the mother’s heart rate will increase and thus increase the demand for oxygen from her heart at a time of decreased oxygen supply. This may cause a potentially serious cardiac event.

Trainers should also be especially conscious to avoid any exercise that may cause abdominal trauma, as this will obviously increase the risk of foetal trauma.

As previously discussed high impact activities should be avoided as they dramatically increase the risk of musculoskeletal injury.

 

Exercise should cease if any of the following signs or symptoms present themselves:

  • Syncope (light-headedness or fainting)
  • Disorientation
  • Vaginal bleeding
  • Lower abdominal pain or cramping
  • Headaches
  • Palpitations
  • Blurred vision

 

Trainers need to be aware that during pregnancy there is a decreased availability of oxygen for aerobic exercise. To this end, a segregated training program may be advisable to ensure that the mother does not become over loaded and to allow adequate recovery time for all physiological systems.

Importantly, pregnant women should be advised against exercise in hot or humid conditions, or in similar stressful environments. They should be advised to wear loose fitting clothing to assist with heat dissipation.

 

Timeframes for progression and exercise selection

0-12 WEEKS

Programs should consist of exercises to develop cardiovascular ability, joint stability, core stability, proprioception and gait ability and flexibility

 

12-18 WEEKS

Maintain stability exercises concentrating on hip and shoulder stability, maintain cardiovascular ability

 

18-32 WEEKS

Decrease any resistance training due to increases in relaxin, cardiovascular should be partial to non-weight bearing, greater focus on core stability and maintaining flexibility.

 

32 WEEKS-Birth

Exercise should be programmed individually based on the ability and desires of the expectant mother:

 

Aerobic:

Approximately 2-3 sessions per week

Intensity 60-70% MHR and RPE

Duration 15-30 minutes

 

Resistance:

Approximately 2-3 sessions per week

Intensity no more than 70% 1RM, decreasing load as pregnancy progresses

Rep range above 10

2-3 sets

 

Core training:

Performed between sets

Low RPE

Slow and controlled movements

General program considerations

  • Maintain adequate hydration at all times
  • Maintain healthy pregnancy weight gains (1-2kg 1st trimester, 0.4kg per week for total of 10-12kg)
  • Ensure additional nutrient requirements are met
  • Have a prolonged cool down after all aerobic sessions
  • Do not start resistance training after week 12 if not already started
  • Have extended warm up and cool down
  • Avoid Valsalva breathing
  • Avoid complex compound or plyometric type exercises
  • Be aware of continued joint laxity throughout pregnancy due to hormonal change
  • Account for a raise of heart rate of about 7 bpm in the first weeks of pregnancy
  • Avoid exercise in the supine position after week 16
  • Do not train in extreme environmental conditions

Training Considerations During Pregnancy Part IV: Medical and Physiological Considerations

Medical and physiological considerations during pregnancy include gestational diabetes mellitus which has risks for both the mother and the foetus, the changes that occur in the cardiovascular, respiratory, endocrine, nervous and gastrointestinal systems during pregnancy, and pre-eclampsia which is characterised by hypertension, proteinuria and severe fluid retention.

 

Gestational Diabetes Mellitus

This involves any degree of intolerance to insulin on the part of the mother that is first recognised during pregnancy. This form of diabetes involves relative resistance to insulin. This form commonly develops when the circulating insulin does not counteract the lowered insulin sensitivity brought on by pregnancy. The causes are not completely understood though there is a belief that it is a survival mechanism for the developing foetus to ensure adequate fuel supply for growth and development. This comes at the expense of the mother’s ability to process glucose.

 

Thus the mother experiences increased glucose levels in the blood at a time when she has a decreased ability to use this glucose. Those who develop this condition are found to be more likely to have larger babies and have an increased risk of developing Type 2 Diabetes later in life.

 

Risks to the mother resulting from GDM:

  • Pre-eclampsia or pregnancy induced hypertension
  • Urinary tract infections
  • Macrosomia (large baby) can lead to difficult delivery or C-section

 

Risks to the foetus resulting from GDM:

  • Heart defects
  • Kidney defects
  • Spinal defects
  • Respiratory distress syndrome (imperfectly expanded lungs)

 

Regular exercise in previously sedentary women can help normalise blood glucose levels, which may help hyperglycaemic effect of the insulin de-sensitivity. Using exercise programs that promote the use of large muscle groups with compound movements can help to increase glycogen utilisation by the mother. The mother’s exercise tolerance is increased for various periods depending on insulin and contractile activity thus helping to normalise blood glucose profiles.

 

High-intensity activities are not advised due to the compounded effect of an increased metabolic rate potentially increasing glycogen usage post exercise. This can lead to potential deficiencies for the child and thus impair development.

 

The decrease in glucose uptake by the muscles may also lead to fatigue during exercise, which may increase the potential risk of injury to joint structures due to the aforementioned lack of stabilisation of the surrounding musculature.

 

Exercise is contraindicated for those with Type 1 Diabetes during pregnancy due to associated hypoglycaemia compounding the effects of insulin treatment.

 

Post-Partum Thyroiditis

This is a condition characterised by inflammation and swelling of the thyroid after giving birth. It causes irregular levels of thyroid hormone production resulting in disruptions in metabolic rate and an increase in the rate at which the mother breaks food down to produce energy. It is a direct result of the increased demand for energy by the foetus for growth and the expectant mothers demands to cope with the rigors of gestation. This increased activity places a large strain on the thyroid gland thus causing it to fatigue and, after birth, decrease production as a result of this fatigue. The effects last no longer than 6 months, however it is difficult to diagnose because symptoms mimic the symptoms of fatigue, depression, and weight change commonly associated with postnatal depression. The two are thus often confused.

The cardiovascular system and pregnancy

Pregnancy causes increased heart rate and oxygen uptake during weight bearing activities. Inactivity can compound the effects of pregnancy and cause further increases in body weight, which can lead to problems such as gestational diabetes and hypertension.

 

Generally non-weight bearing activities are advised, as they do not place as big a strain on the mother’s joints thus decreasing the risk of excessive force being placed through lax, unstable joints. It must be noted that heart response to exercise varies greatly between individuals and will be affected by many variables including prior exercise experience, pre-pregnancy conditions and genetic factors such as soma type, which will effect muscle specialisation. Thus it is obvious that the trainer must be aware that different bodies respond differently to certain types of exercise.

 

Pregnancy increases blood volume by 40-50%. However, red blood cell volumes increase by only 18-25% depending on the iron status of the woman. As a result of these decreases in haemoglobin concentrations, the mother’s ability to effectively transport oxygen to working muscles to maintain activity may be compromised. This may magnify the potential feelings of fatigue. At about 32 weeks this effect can result in the development of dilutional anaemia.

 

This increase in blood volume is also accompanied by increases in cardiac output by as much as 50% as the body attempts to maintain normal blood circulation and cope with the additional volumes of blood. There are large increases in blood flow to the uterus, placenta, kidneys, and skin to ensure adequate nutritional supply to the foetus as well as to deal with the removal of the increased waste produced during gestation and assist thermoregulation to combat the increased heat production caused by increased metabolic rates.

 

Stroke volumes rise by week 8 and continue to rise to maximum levels during the second trimester.

 

The Endocrine System and Pregnancy

Increases in insulin can cause possible magnified hypoglycemic responses during pregnancy. This is especially true late in the pregnancy. This increase in insulin increases the risk of gestational diabetes as well as affecting the mother’s ability to produce energy for working muscles.

 

The placenta secretes Human Placental Lactogen (HPL), which works with oestrogen and progesterone to prepare breasts for lactation. However, HPL also causes glucose sparing. This results in the metabolism of fatty acids thus compounding the effects of insulin sensitivity and increasing the risk of ketone production. This has the potential to increase the risk of hypertension development and renal dysfunction.

 

During the pregnancy, there are increases in vitamin D levels and the plasma levels of parathyroid hormones. This causes a positive balance during pregnancy. This assists in the mineralisation of bone for the foetus. It is essential that the mother take adequate levels of calcium at this stage or she risks the foetus stripping calcium from her skeleton to ensure adequate development.

 

Fat accumulation ceases during the second half of pregnancy due to cortisol, growth hormone and insulin continuing to rise along with the growing energy demands of the foetus.

 

It is important that increasing levels of relaxin are kept in mind at all times. These levels will peak between the eighteenth and twenty-second weeks. The higher level of relaxin will affect ligament laxity and which will continue throughout pregnancy until labour. It is important to note that ligament laxity can remain for as long as six months after birth with pubis symphysis instability occurring up to 8 weeks after birth. As a result, heavy loading lower body exercise and excessive high-intensity weight bearing exercise should be avoided until after this point.

The respiratory system and pregnancy

During pregnancy oestrogen causes the nasal mucosa to become oedematous and congested potentially causing stiffness and bleeding. This can lead to the potential for increased nosebleeds under strain.

 

There is an increased ventilatory response during rest and sub maximal exercise, particularly in the later stages of pregnancy. This is possibly due to maternal hyperventilation, which can be attributed to progesterone and CO2 sensitivity. This sensitivity occurs to maintain respiratory responsiveness.

 

A numbing of the autonomic nervous system may also occur and lead to poor intercostal muscle activation. This can be exacerbated by high-intensity cardiovascular activity. The mother may also complain of shortness of breath during the later stages of pregnancy due to restriction of her diaphragm by the growing foetus.

The gastroinstestinal system and pregnancy

The expectant mother may experience nausea and vomiting due to increases in her hormone level. This can decrease the kilojoules available and affect the nutritional status of both the foetus and mother. It can also affect the energy available to the mother for activity.

 

The expectant mother may also experience heartburn and constipation due to the slowing down of peristalsis.

 

The Nervous System and Pregnancy

Pregnancy can cause mood changes, increased anxiety, amnesia which can all impact on the mother’s mental well-being. It may also cause a slight decrease in cognitive ability, which may lead to increased risk of falls during complex movements.

Thermoregulation and pregnancy

Normal core temperature sits at about 36 degrees Celsius. However, the expectant mother’s temperature will normally sit higher by about 0.5 degrees.

This is due in part to increased metabolic rates from foetal growth. The foetus produces heat as a result of metabolic activity but it does not have the ability to dissipate this heat. Heat is therefore transferred to the mother.

 

This gradient may also reverse and the heat produced by the mother may be transferred directly to the child. It is, therefore, essential that a pregnant woman avoid overly hot and/or humid environments and not overly exert herself during exercise. Maintaining adequate hydration levels is vital for thermoregulation and can help ensure this does not occur.

 

Pre-Eclampsia

This is characterised by hypertension, proteinuria, and severe fluid retention.

Genetic factors and the functions of the placenta play a major role in its development. It is also closely related to insulin resistance and associated conditions such as gestational diabetes, polycystic ovary syndrome and obesity.

 

Pre-eclampsia can develop at any stage during the second half of pregnancy and can potentially involve all maternal organs. In severe cases it may progress to seizures known as eclampsia, which are linked to high blood pressure. It has the potential to lead to kidney or liver failure, clotting problems and death.

 

Adequate nutrition is particularly important in the prevention and management of pre-eclampsia.

 

The mother is particularly at risk if she has any of the following:

  • It is her first pregnancy
  • She has pre-existing high blood pressure or other forms of vascular disease
  • She has a family history of pre-eclampsia or eclampsia
  • She is a diabetic
  • There are multiple foetuses involved.

 

Pre-eclampsia can have several effects on the on the unborn child:

A sluggish blood flow as a result of the hypertension and increased blood volume means the baby can become starved of oxygen and nutrients, which may result in premature birth.

 

In severe cases the mother may experience vaginal bleeding and abdominal pain as a result of the placenta separating from the uterine wall. This can result in the death of the child if not treated fast enough.

 

The trainer should be on the look out for the following signs and symptoms:

  • dizziness
  • headaches
  • visual disturbance such as seeing flashing lights
  • abdominal pain just below the ribs
  • nausea and vomiting

Training Considerations During Pregnancy Part III: Common Anatomical Considerations

Common anatomical considerations during pregnancy include weight gain and associated shifting of the centre of gravity, postural changes, and joint laxity due to hormonal changes.

 

Weight Gain and Shifting Centre of Gravity

The rapid weight gain and altered weight distribution typical in pregnancy leads to a number of postural and biomechanical changes in the mother’s body. Whilst the pregnancy obviously affects posture, posture can also be affected by employment demands, daily activities and poor habits. These can all place stress on the skeletal system, vertebrae and the pelvic girdle.

 

As the foetus develops the mother’s centre of gravity shifts forwards and upwards. This growing abdominal region and the resultant changes in the centre of gravity of the mother can have a marked effect on her balance and on her ability to rapidly change direction. This shift in centre of gravity also destabilises the mother’s core and increases the risk of tripping and falling.

Posture and pregnancy

At the same time increased lumbar lordosis increases anterior slide of the lumbar vertebrae thus increasing the risk of intravertebral disc pressure and hence the risk of localised back pain.

 

Increased tightness of the musculature surrounding the spine along with increased thoracic kyphosis and an increase in breast size can increase round shoulder appearance in the mother. This increased breast size is due to increases in HPL (Human Placental Lactogen) hormones. As the mother’s shoulders begin to round the shoulder abductors are affected and compressive forces in the shoulder are increased.

 

This rounding of the shoulders also causes the mother’s head to move forward, leading to additional stress on the posterior neck musculature. This will also cause tightness in the upper trapezius. This may increase intravertebral pressure in the cervical region and cause the mother to experience headaches.

 

The trainer’s focus should be on instructing the mother in proper postural habits to minimise strain, especially on the back. At all times the trainer should be concentrating on decreasing the risk of injury.

Joint laxity

 

The mother’s many hormonal changes may cause joint laxity and hyper-mobility. There is an increased laxity in joints due to the release of relaxin by the placenta. This is designed to increase laxity in the pelvic ligaments and pubic symphysis, thus widening and allowing greater flexibility of the birthing canal.

 

This laxity can lead to a waddling gate and increase the sheering effects on the pelvis joints during movement. The effect of relaxin also has a global effect on all the joints of the body, increasing their flexibility and thus decreasing the stability of the joint. This decreased stability increases the susceptibility to injury during gross or compound movements. The mother may experience significant laxity changes between the first and second baby.

Training Considerations During Pregnancy Part II: Exercise Programming Considerations Benefits of Exercise During Pregnancy

During pregnancy women free from medical complication can freely be advised to participate in some moderate forms of physical activity at least twice a week. If their attending physician deems the client low risk, then exercise does not raise any immediate concerns nor pose any threat to the pregnancy.

Just as exercise programming for non-pregnant women aims to develop cardio-respiratory and muscular fitness, this should also be the focus for low-risk pregnant women. The trainer requires an additional focus on maintaining the mother’s functional ability and offsetting the negative effects of the pregnancy.

It has been shown that women who exercise before and during pregnancy experience less weight gain, deliver smaller healthier babies, have greater control during labour and recover to full functionality quicker post birth.

Despite the many and varied risks associated with exercise during pregnancy, there are at least as many and benefits. In most cases, the benefits will far out weigh the risks.

 

Benefits include:

Increased Fitness
Increased fitness may help with feelings of fatigue whilst at the same time increasing joint stability due to increased muscular endurance capabilities. Increased fitness will also help the mother cope with labour better.

Decreased Risk of Excessive Weight Gain
This may decrease negative self-image feelings and decrease the risk of developing gestational diabetes.

Prevention and Relief of High Blood Pressure
This may decrease the potential for the development of pre-eclampsia later in the pregnancy.

Prevention of Gestational Diabetes, and Associated Physiological Complications
Maintaining blood glucose profiles reduces the risk of renal dysfunction, hypertension and developing type 2 diabetes later in life.

Prevention of Stretch Marks
These may have an effect on the mother’s positive self-image.

Prevention of Varicose Veins
Getting the blood pumping increases circulation thus decreasing the rate of localised muscle fatigue as well as the risk of peripheral muscular cramping and limiting negative body image feelings.

Promoting Faster Delivery
This decreases the stress placed on both mother and child during labour and as a result decreasing the potential for complications during labour.

Faster Recovery of Functional Abilities After Childbirth
This allows the mother a greater ability to care for both herself and the baby.

Improved Psychosocial Wellbeing
Improved mood and increasing positive body image.

Prevention of Leg Cramps
Leg cramps are associated with decreased circulation to the peripheral muscles.

Improved Posture
Improved posture through exercise may decrease the occurrence of muscular skeletal imbalances which increase uneven force distribution within the joint. This helps to reduce joint pain during the pregnancy and associated continued complications after childbirth.

Contraindications to Exercise During Pregnancy
Contraindications to exercise during pregnancy are extremely important.

They can be divided into absolute and relative contraindications for assessment.

Absolute Contraindications include:

  • Ruptured membranes
  • Prior premature labour
  • Heart disease including circulation problems and heart valve dysfunction
  • Restrictive lung disease
  • Clots in arms or legs (venous thrombosis or pulmonary embolism)
  • Premature labour during current pregnancy
  • Pregnancy induced hypertension
  • Incompetent cervix
  • History of miscarriages
  • Continued bleeding in second or third trimester
  • Placenta praevia (where the placenta is fixed to the lower segment of the uterus and thus can obstruct the cervix and cause haemorrhage prior to or during labour)

Relative contraindications including:

  • Chronic bronchitis
  • Anaemia
  • Hypertension
  • Heavy smoking
  • Morbid obesity
  • Underweight i.e. where BMI< 12
  • Poorly controlled Type 1 Diabetes
  • Extremely sedentary lifestyle
  • Cardiac arrhythmia
  • Seizure disorder
  • Thyroid disorder
  • History of bleeding during pregnancy

Warning Signs
The trainer should be aware that there are a number of warning signs that the exercise program is creating potential issues for the pregnant mother.

Pain in the Mother’s Back Without Associated Shooting Pain or Numbness
This may be an indication of poor joint alignment. This can cause pressure on the articular structures of the vertabral column and increase the risk of degeneration. Applying forces through the back can accelerate this risk.

Pain in the Mother’s Back with Associated Radiating Shooting Pain and Numbness
Numbness or shooting pain down the legs or into the arms may be an indication of nerve entrapment and needs immediate assessment by a doctor or physiotherapist.

Pain in Pubic Region
Pain in the pubic region be an indication of a problem with the pubis symphysis due to laxity caused by relaxin. This may lead to a sheering effect on the joints and may develop into chronic osteitis pubis. This can persist post pregnancy.

Shortness of Breath
This may indicate maternal hyperventilation, restriction of the mother’s diaphragm, or decreased neural sensitivity. These may lead to poor activation of the intercostal muscles which can lead to decreased oxygen availability for both mother and child.

Palpitations
Palpitations may indicate desensitisation of autonomic neural control of the heart.

Faintness
Faintness may be the result of decreased glycogen sensitivity or decreases in oxygen availability.

Vaginal Bleeding
May be an indication of placenta praevia.

Vaginal Fluid Loss
Vaginal fluid loss may be an indication of pre-term membrane rupture or placental complications.

Difficulty in Walking
This may be an indication of complications with the hip joint including the sacral-iliac joint. It may also indicate pubis symphysis separation.

Uterine Contractions
Uterine contractions may indicate the start of labour.

Absence of Foetal Movement
This may indicate foetal distress.

Tachycardia (High Heart Rate)
Tachycardia may indicate the presence of hypertension or early signs of pre-eclampsia.

Training Considerations During Pregnancy Part I: Introduction & Safety Considerations

Whilst pregnancy can be a fantastic and rewarding experience for many mothers as they prepare to bring a new life into the world, the potential for danger and complications cannot be disregarded. This is especially true when the mother is undertaking an exercise regime as discomfort, loss of function, injury and complications involving both the mother and the foetus can arise if the training is not carefully controlled.

In this series of articles, we examine four major aspects that a trainer should consider when dealing with a pregnant mother. These considerations should all be taken into account in order to achieve the best possible outcome.

1. Exercise Programming Considerations
2. Common Anatomical Considerations
3. Medical and Physiological Considerations
4. Exercise Selection Considerations

Whilst exploring these considerations, the following factors should form the basis for any decisions made as all will impact on the mother’s ability and safety:

Stage of Pregnancy
The stage of the pregnancy will have a profound effect on the type of exercise selected as well as the intensity and duration of the program. The stage of pregnancy affects multiple factors for exercise considerations – for example, balance, hormonal issues and safety of mother and child.

Potential for Injury
Whilst devising a program and supervising the mother the trainer should be aware that there are many factors specific to the pregnant mother that have the potential to cause injury. Changes in the centre of mass of the mother, potential changes in force application and the absorption capacities of the mother’s joints, neural factors and the hormonal impact on the mother’s ligaments are all crucial to consider.

Exercise Experience of the Mother
As with any client, experience is a primary factor in determining the approach the trainer should take. The type of exercises selected and the intensity of these exercises will clearly depend on how long and how well the mother has trained prior to pregnancy.

Expectations of the Mother
Again, as with any client, the trainer must establish what the goals of the mother are and take these into account in order to devise individualised programs. It is important that the trainer designs a program that allows the mother to achieve her goals whilst minimising any potential harm to her or her baby.

Level of Comfort During Exercise for the Mother
Each woman is different and thus will respond differently to the pregnancy and to any exercise. The trainer must establish the limit at which the mother can comfortably complete any exercise, and likewise, ensure these limits are not exceeded to ensure the continued safety of the mother and her unborn child.

As a trainer develops a program for an expectant mother it is also important to consider certain physiological issues impacted by pregnancy:

Heart Rate May Not Be an Accurate Indicator of Intensity
When writing any exercise program for pregnant mothers, cardiovascular endurance is a priority. As such, it is essential that the trainer can monitor the client’s intensity to ensure optimal stimulus to the system is applied to allow development without risk. As a result it is important to note that, unlike with most clients participating in cardiovascular endurance programs, heart rate is not an appropriate measurement of intensity for a pregnant woman. This is due in part to increases in sub-maximal heart rate and the possible blunting of the nervous system to exercise in late gestation. As a result it is advisable to utilise RPE as a measure instead.

Exercise May Add to the Feeling of Fatigue
This is largely due to dilutional anaemia, which is caused by an increase of blood volume and a limited increase in haemoglobin. This hypoglycemic effect of pregnancy normally occurs during prolonged or intense exercise or prolonged fasting and thus may increase feelings of fatigue. Prolonged exercise may cause increases in maternal temperature and may reverse gradient.

Additional Factors
There additional factors are to be considered when developing a program for a pregnant woman. These are generally incidental or secondary effects caused by primary exercise selections:
• Increase in maternal temperature
• Circulating stress hormones
• Ensuring adequate caloric expenditure
• Biomechanical stress
• Effects on the foetus such as hyperthermia, trauma and decreased nutritional availability

Take a read of the second part of the series: Exercise program considerations while pregnant