The Active Female: Health Issues Throughout the Lifespan 2008th Edition

17. Prevention and Management of Common Exercise-Related Musculoskeletal Injuries During Pregnancy

Mimi Zumwalt  and Brittany Dowling 

(1)

Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX 79430-9436, USA

(2)

Department of Health, Exercise, and Sports Sciences, Texas Tech University, 1545 Shadowtree Court, Colorado Springs, CO 80921, USA

Mimi Zumwalt (Corresponding author)

Email: mimi.zumwalt@ttuhsc.edu

Brittany Dowling

Email: dowlingb86@gmail.com

Abstract

Pregnancy causes additional alterations to the female athlete’s body that she must be aware of. The hormonal, bodily, and biochemical changes that accompany the pregnant state can incite new symptoms and may cause additional avenues for musculoskeletal trauma. Precaution does need to be taken by the pregnant female when participating in certain physical activities. However, in general the female athlete can be very active up until delivery if she’s careful to protect the fetus. An already existing injury can be exacerbated by pregnancy, although in most cases symptoms tend to cease shortly after delivery. On the other hand, maintaining an active lifestyle while pregnant helps the mother as well as the fetus to be healthier in the long run.

Keywords

PregnancyDeliveryFetus

17.1 Learning Objectives

After completion of this chapter, you should have an understanding of:

·               The pertinent female anatomy involved in pregnancy and how the surrounding musculoskeletal structures are affected by the gravid uterus and growth of other essential organs

·               The accompanying physiological alterations along with other associated systemic changes affecting the pregnant woman’s ability to exercise

·               The anatomical and structural issues contributing to or detracting from performing different types of exercises while pregnant

·               Different prevention measures for common musculoskeletal injuries incurred with exercising while being pregnant, to include current recommended standard medical guidelines

·               Various modes of treatment for common musculoskeletal injuries which can be exacerbated or sustained by a woman while exercising in the pregnant state

17.2 Introduction

Pregnancy is a time of tremendous change for a woman’s body, not only involving the anatomical structures but also physiologically. As a matter of fact, these bodily changes persist for the entire duration of pregnancy (generally 9 months) and may continue even beyond childbirth. These morphological, hormonal, and biochemical alterations may incite new symptoms and predispose the pregnant woman to a myriad of injuries involving the musculoskeletal system, or even aggravate previously preexisting orthopaedic conditions. Therefore, the expecting female must try to protect her own body from physical harm, and, at the same time, she also needs to make sure that the fetus she is carrying remains safe from any injury. This does not mean that she must feel completely confined and give up exercising altogether. However, she has to be cognizant of the fact that she cannot and should not train as hard, or intensely, as prior to conception. She must also modify the manner by which she exercises and avoid certain athletic activities, due to the potential increased risk of trauma to herself and/or the fetus. Beyond these specific considerations, a pregnant woman can engage in various forms of physical activity as long as she remains strict in following current standard medical guidelines, takes measures to prevent musculoskeletal insult, and seeks appropriate orthopaedic care if she ends up sustaining injuries from physical training [15].

This chapter will focus on different potential musculoskeletal injuries and conditions which can occur and/or become exacerbated with exercising while being pregnant, along with various methods of prevention and management of these more common orthopaedic injuries.

17.3 Research Findings and Contemporary Understanding of the Issues

17.3.1 The Pertinent Female Anatomy Involved in Pregnancy and How the Surrounding Musculoskeletal Structures Are Affected by Organ Growth

The important anatomical female structures involved in pregnancy include the main organ, the uterus, which is connected to a pair of ovaries by two fallopian tubes (Fig. 17.1).

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Fig. 17.1

Female reproductive unit

This female sexual complex is completely contained within the bony pelvis and totally surrounded/supported by soft tissues. Sex differences exist in terms of the female pelvis morphology in general. Although anatomically and structurally similar to the male pelvis, the female pelvis is configured differently. The female pelvis is built larger in all dimensions to accommodate a fetus and allow for childbirth. The basic shape of the female pelvis is wider, rounder, and deeper. Specifically, the pelvis is composed of four main bones: the ilium, the pubis, the ischium, and the sacrum. Two of these large bones join anteriorly at the pubic symphysis in the midline and posteriorly via the two sacroiliac (SI) joints (Fig.17.2).

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Fig. 17.2

Pelvis morphology

The formation of the pelvic basin thus consists of bony structures strengthened by ligaments, partially covered by muscles, and entirely lined by fascia. The anterior wall of the pelvis forms from the two pubic bones connected in the midline by the symphysis. Each of the lateral walls is formed by the ilium, obturator foramen, sacrospinous/sacrotuberous ligaments, and obturator internus muscles. The posterior wall is composed of the sacrum, coccyx, and piriformis muscle. Finally, the pelvic floor is made up of the levator ani and coccygeus muscles, along with associated fascial covering. The latter muscle group, however, can only be palpated internally through a rectal exam [26].

In addition, various ligaments which attach from the spine to the pelvis, along with different musculotendinous units originating from the pelvis and inserting onto the lower extremities, also become affected by the gravid uterus, especially over time as the fetus grows in size through the three trimesters. Specifically speaking, the iliolumbar ligaments, the iliopsoas tendon, the rectus abdominis, internal/external obliques, the quadratus lumborum, the erector spinae, and the pelvic walls/floor musculature are the main contributors to the “core” group of supporting structures surrounding the fetus, which inevitably will be affected gradually by fetal and other organ growth within the expanding uterus [26] (Fig. 17.3).

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Fig. 17.3

Gravid uterus

Furthermore, other structures which also play a role in changing a woman’s anatomy after conception are the mammary glands. As the breast tissue enlarges in preparation for hormone secretion and milk production, the surrounding skeletal framework, i.e., rib cage, thoracic spine, chest, and upper back, along with their attached muscles, must accommodate accordingly (consequently receiving more load) to support these ever-enlarging breasts [78] (Figs. 17.4 and 17.5).

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Fig. 17.4

Truncal musculature—ventral view

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Fig. 17.5

Truncal musculature—dorsal view

17.3.2 The Physiological and Other Associated Systemic Changes Affecting the Pregnant Woman’s Ability to Exercise

After conception, the woman’s pregnant body not only is affected by structural modifications as previously mentioned but also is influenced by hormonal and biochemical changes. These changes occur in order to provide normal fetal development and parturition (delivery). However, the changes can also cause an array of issues affecting the lower extremity [910].

Shortly after the sperm fertilizes the egg, implantation occurs in the uterus. Once fertilization occurs, the placenta, a unique organ formed to help sustain life for the fetus, which also acts as an endocrine gland, starts to produce numerous hormones. Human chorionic gonadotropin (HCG) is the initial key hormone secreted by the placenta and is used as an indicator of pregnancy when testing the urine or serum. HCG then, in turn, stimulates the formation of relaxin. Relaxin is an estrogen-dependent hormone produced by the corpus luteum (another pregnancy-related structure) that causes softening and stretching of maternal pelvic ligaments and the pubic symphyseal joint. This allows better accommodation of the expanding uterus as well as of delivery. Relaxin has been shown to work by affecting the collagen fibers, increasing water content of soft tissues, and activating fibroblasts in the synthesis of new collagenous tissue [11]. While relaxin is produced in the normal monthly menstrual cycles, levels increase ten times the usual amount during pregnancy [9]. Relaxin serum levels increase during the first trimester and then level off during the second and third trimesters. Other hormones of pregnancy originating from the corpus luteum include but are not limited to progesterone (establishes and sustains the fetus within the uterine cavity), estrogen (responsible for endometrial/uterine lining growth among other functions), and prolactin from both the pituitary and uterus (stimulates the breast milk apparatus among other roles). Additionally, other maternal hormonal alterations affecting a pregnant woman’s ability to exercise involve insulin (affects blood glucose levels), cortisol (influences gain in adipose tissue and thinning of the skin leading to easy bruising), thyroid hormone (responsible for increased basal metabolic rate and pulse at rest), and parathyroid hormone (regulates calcium absorption from dietary sources) [810].

The interaction between fetal and maternal tissues causes metabolic changes, which will also influence a pregnant woman’s body. Specifically, the normal course of pregnancy induces weight gain on an average of about 10–15 kg (20–40 lbs), with 50 % from evolving maternal tissues and 50 % from the placental–fetal complex. Two phases encompass the process of fetal–maternal metabolism. The first half of pregnancy is anabolic for the mother and the second half catabolic (“accelerated starvation”). The catabolic state provides an anabolic environment for the fetus, thus enhancing normal fetal growth. However, the catabolic state is extremely taxing in terms of draining energy from the mother [812].

Another significant physiological alteration of pregnancy includes generalized/dependent soft tissue edema from retained extracellular fluid in the periphery of the body. Edema could cause inflammation of musculotendinous structures or entrapment of neural tissues, possibly interfering with certain movements involved with different activities or exercises [2].

17.3.3 The Anatomical and Structural Issues Contributing to or Detracting from Performing Different Types of Exercise While Pregnant

The main anatomical issue to consider regarding a woman’s pregnant body is the physical change resulting in the forward shift of the center of mass caused by hypertrophy of breast tissue, along with the growth of the fetus inside the mother’s uterus. The change in the center of mass moves her body weight more anterior and inferior [13]. To compensate for the increased weight and change in the center of mass, there is an increase in lumbar lordosis, thoracic kyphosis, posterior upper body tilt, and sagittal pelvic tilt [13]. This puts added stress on the SI ligaments and musculature. However, attempts to relocate the center of mass and rebalancing the head over the pelvis in the upright position become less effective over time, due to relaxation and stretching of the local supporting ligaments/connective tissues. This, in turn, contributes to mechanical low back strain (50 % prevalence) along with pain in the pelvic area and SI joints [3714]. Widening of the pubic symphysis (up to 1 cm), starting near the end of the first trimester, is associated with tenderness and is aggravated by exercising. These painful symptoms appear to correlate with serum relaxin levels, especially in the first 12 weeks, when serum concentration peaks. Between the fourth and fifth months of gestation, the level of relaxin decreases and then reaches a steady level about half the quantity of its previous peak during the first 3 months. Interestingly, the level of relaxin does not seem to correlate with measured quantity of laxity in joints [215]. As a corollary, the accompanied weight gain also places additional mechanical strain on the lower back, pelvis, and SI areas. Muscular forces increase as much as 100 % for only a 20 % increase in weight, adding to the symptoms of joint discomfort [2]. In fact, forces across the hip and knees during pregnancy may also reach as high as 100 % compared to normal when engaged in impact activities, which potentially could compound more damage to these large weight-bearing joints [14]. Other biomechanical alterations which accompany the pregnant body include increased pressure on the pelvic floor musculature; tightening/shortening of the pectoral, iliopsoas, hamstring, and lumbar extensor muscles; lengthening and weakening of the rectus abdominis and gluteal muscles; and upward flaring of the rib cage. In short, the hormone relaxin contributes to near-global soft tissue elongation within the body, predisposing the pregnant woman to increased risk of overuse injuries with exercising, contributing to tendon strains and ligament sprains [71416].

17.3.4 Common Musculoskeletal Injuries/Conditions Which Can Be Incurred During and/or Aggravated by Exercise While Being Pregnant, Along with Preventative Measures and Current Standard Medical Guidelines

Although pregnancy induces laxity of tendinous and ligamentous structures secondary to hormonal influence as previously noted, no specific exercise-related injuries have been cited as directly caused by being pregnant [17]. However, some more common musculoskeletal conditions do exist which can be initiated or exacerbated while exercising in the pregnant state. Typical problems include low back pain; groin pain; pelvic girdle, pubic symphysis, and sacroiliac joint pain; hip/lower limb pain; leg cramps; diastasis recti; meralgia paresthetica; carpal tunnel syndrome; and de Quervain’s stenosing tenosynovitis [23715].

The incidence of low back pain (LBP) during the course of pregnancy is high, occurring in at least 50–70 % of pregnant women. The rate of LBP increases with increasing age and even more so in those females with a previous history of back pain and prior births. Relaxin plays a major role in contributing to LBP; in fact, the highest serum levels of relaxin during pregnancy have been associated with the greatest amount of pain [18]. Almost one third of afflicted women have to refrain from performing activities of daily living due to their back symptoms. Surprisingly, the amount of weight gain while pregnant does not seem to proportionately correlate with the extent of back problems. As previously noted, as a compensatory mechanism toward the growing fetus, higher shear forces occur on the dorsal/posterior aspect of truncal soft tissue structures which, combined with abnormal pelvic rotation and poor posture in the erect position, predispose certain pregnant women to lumbar discomfort [237]. Similarly, increased upper spinal segment stress also occurs as a result of breast tissue gaining in size and weight, thus consequently causing the shoulders to sag and the neck to ache as well [23].

Variations of LBP experienced by the pregnant woman include pelvic girdle pain (PGP), SI joint dysfunction, and symphysis pubis insufficiency. Their incidence ranges from approximately 4 to 90 %, with 9 to 15 % having severe symptoms. The former entity (PGP) is more generalized and the latter two conditions are more specific, describing posterior weakening and anterior pelvic widening, respectively. Earlier studies have shown that separation of the pubic symphysis from 1 to 2 cm is associated with minimal discomfort, while widening more than two centimeters is associated with a great increase in groin pain. Later studies, however, could not replicate these findings in terms of correlation between the degree of widening and clinically relevant symptoms, although approximately one out of three women does have problems sleeping due to their pelvic pain [3151619]. Regarding the absolute width of separation, once the symphyseal diastasis approaches 5 cm, however, operative management may have to be considered from a mechanical standpoint since the pelvis has now become an unstable structure, depending on the stage of pregnancy and potential risk to the fetus [131516].

Osteitis pubis is another condition that affects the pubic symphyseal joint during pregnancy. This results from resorption and then spontaneous reossification of the adjacent pubic bones, leading to severe, rapid radicular pain from the central pubic and groin area down both thighs which progresses quickly over a few days and is worsened by lower limb movement. Osteitis pubis is usually transient and needs only symptomatic treatment, resolving spontaneously within several days to a few weeks [2]. Most of these conditions do have a common denominator, however, resulting from relaxation of different articulations of the pelvis, which allows greater joint mobility of the pelvic bones, inciting symptoms of pressure and pain from less skeletal support and therefore lack of stability [131516].

Lumbosacral/pelvis pathologies occurring during pregnancy may not be solely due to hormonal changes leading to mechanical alterations; however, there may be other preexisting conditions which are exacerbated by changes of pregnancy [16]. For example, lumbar degenerative spondylolisthesis (anterior/posterior vertebral translation) or true spinal discal problems can exist concurrently with LBP as well (Fig. 17.6).

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Fig. 17.6

Spondylolisthesis

Fortunately, lumbar disc herniation is quite rare, occurring only in one out of 10,000 pregnant women [23]. Likewise, the majority of the above mentioned conditions do tend to resolve on their own after a few weeks postpartum, thus not requiring actual medical management [16]. Lower back pain is usually aggravated by activity and is relieved by sitting or lying down. Symptoms can also be relieved by limiting physical activity, wearing low-heeled shoes, and applying moist heat compresses. Sometimes, the use of a lumbo–sacroiliac corset/brace can relieve pain by providing external back support.

Diastasis recti is the separation of two bands of the rectus muscle on either side of the linea alba due to stretching of the waistline. This occurs in 75 % of pregnant women as an attempt to increase volume for accommodating fetal growth. This frontal core division of connective tissue causes the abdominal musculature to weaken, thus providing less support dorsally and adding even more to chronic low backache [720]. One study showed that pregnant women who did not exercise had a 90 % incidence of diastasis recti as compared to 12.5 % women who physically train using their transverse abdominis during their workouts [21].

Most musculoskeletal changes affect the lower limbs of pregnant women which can be exacerbated by exercise. This is due to the global effects of relaxin causing ligamentous laxity that can lead to lower extremity dysfunction and pain. The lower extremity joints and limbs must adapt to the change in center of mass and increased body weight by absorbing additional forces. The hip is the most commonly affected area of increased load; it is estimated that 64 % of pregnant women experience hip pain [2223]. Hip pain has been linked to transient osteoporosis of the femoral head as well [23]. This idiopathic entity usually occurs during the third trimester, presents with an antalgic gait, and is characterized by pain and limitation in hip range of motion. Pain usually is gradual and exacerbated during weight-bearing activity. The symptoms are similar to pelvic instability and may be incorrectly diagnosed as such. If the osteoporotic hip condition is not recognized, continued weight bearing could cause a femoral neck or intertrochanteric stress fracture. Other skeletal sites, including the sacrum, tibia, rib cage, and spine, may also be afflicted with osteopenia and subsequently increased risk of osteoporotic fractures during pregnancy. The third trimester is particularly an issue for stress fractures because of the large weight gain causing an even greater increase in loading. Treatment needs to include protection of the injured joint to avoid further trauma to the same area. A decrease in activity and in some cases bed rest may need to be prescribed until the painful symptoms are alleviated. Additionally, the use of crutches during weight bearing/ambulation will help to eliminate excessive forces on the hip. If a fracture does indeed occur, surgery will be required to help avoid osteonecrosis, nonunion, and degenerative osteoarthritic changes of the hip [22].

Knee pain occurs in roughly 22 % of pregnant women [2224]. As discussed above, a limited range of motion at the hip can be attributed to hip pain. The decreased range of motion at the hip causes a decrease in hip moment and an increase in knee moment. Relaxin causes a decrease in joint stability, which puts more strain on both the hip and knee articulation. Increased strain plus decreased stability allows for greater forces impacted to the acetabular labrum in the hip or cartilage in the knee, predisposing the pregnant woman to a higher chance of injury resulting in mechanical symptoms such as popping and catching. Again, this is dependent on the stage of pregnancy and degree of loading activity. Finally, recurring patellofemoral pain and ankle sprains are two more orthopaedic conditions commonly found during pregnancy. This should be taken into consideration when planning what sort of exercise program would present minimal risk for the expecting mother to participate in so she won’t experience pain and problems [2].

Foot pain is also prevalent in pregnant women, estimated to be at 42 % [22]. Again, this is due to the effects of relaxin on surrounding supportive ligaments. Block et al. found an increase in subtalar and first metatarsophalangeal joint range of motion in the feet of pregnant women [22]. Laxity of the tibialis posterior tendon can cause a 1 cm drop of the talar head, creating a pronated midfoot [23]. The pronated foot and partial longitudinal arch collapse thus creates flattened feet, especially on the stance phase of gait. Studies have found significant changes in foot structure due to pregnancy by measuring locations of anatomical bony landmarks [25]. This change in foot structure due to the effects of relaxin causes an alteration in ambulation. Dynamic gait analysis of shoe wear patterns demonstrates higher forces in the foot while walking during pregnancy [23]. Subsequent adjustment to the change in foot structure and increased loads can cause foot discomfort and pedal pain, among other symptoms [23].

Leg cramps are experienced by about 15–30 % of pregnant women, more often in the latter part of the second and third trimesters, with 75 % happening during nocturnal hours. These extremely strong, fast muscular contractions are severe and very painful, enough to awaken the pregnant woman from deep sleep. Cramps generally occur in the calf muscles and sometimes in the thigh and last from a few seconds to several minutes [26]. The cause of this leg muscle tetany may be due to electrolyte imbalances, primarily insufficient intake of calcium and magnesium. Relaxin has been shown to inhibit calmodulin and calcium influxes into the uterus, allowing for uterine relaxation, and thus prevents premature contractions, causing all muscles in the body to be calcium deficient [27]. The fetal requirement of high calcium levels depletes the quantity of maternal calcium, leading to hypocalcemia. Oral administration of calcium is an effective treatment for muscle cramps. Hammar et al. gave pregnant women 1 g of calcium twice a day for 2 weeks and found a decline in the prevalence and severity of leg cramps [28].

Musculoskeletal conditions occurring in the upper extremity and compression neuropathy from peripheral edema do not tend to be as serious as some of the lower limb conditions because weight bearing is not a factor. However, the quantity of retained fluid can accumulate as much as 6.5–7.5 l a day, causing dependent/pitting edema, especially in the lower limbs [3]. Anatomical issues predisposing the pregnant woman to peripheral nerve injury include certain areas being more prone to excessive pressure and/or existing at superficial locations. Common sites of compressive neural lesions involve the median nerve at the wrist causing carpal tunnel syndrome, the common peroneal nerve at the lateral leg/proximal fibula, and the lateral femoral cutaneous nerve of the anterior hip/thigh. The latter, also known as meralgia paresthetica syndrome, occurs over ten times more often in pregnant women; and the risk is increased even further with associated obesity and diabetes [23].

De Quervain’s disease occurs also more commonly during pregnancy on the radial aspect of the wrist. The location of this condition is due to/aggravated by repetitive motions and is influenced by prolactin, relaxin, and progesterone. This overuse type of injury involves inflammation of two tendons of the first dorsal wrist compartment controlling thumb motion: the abductor pollicis longus and the extensor pollicis brevis. Again, these are only temporary conditions, which will resolve spontaneously once the hormonal milieu returns to normal status post delivery [3].

Prevention of trauma is the best management because it is difficult to treat an injury in a pregnant woman. Exercise remains the best preventative medicine modality. Current standard medical guidelines for the prevention of orthopaedic injuries and exercising during the pregnant state stem from the American Congress of Obstetricians and Gynecologists (ACOG). As a preface to recommending a training program, the majority of studies have found that exercising has a primarily neutral or positive effect on the pregnancy course and its outcome (labor and delivery) [231720]. When considering an exercise prescription, a balance must be sought between the possible harmful effects to the mother and fetus and the potential health benefits to both. In terms of duration of physical activity, it is recommended that a woman having an uncomplicated pregnancy engage in moderate exercise sessions for 30–45 min/day up to 7 days a week. This is also supported by the American College of Sports Medicine (ACSM) and Centers for Disease Control and Prevention (CDC) [2932].

Specific precautions while exercising in the pregnant state include avoidance of visceral shunting of blood flow and therefore prolonged motionless standing (pedal blood pooling and risk of syncope) and excessive supine positioning, especially after the first trimester (to minimize hypotension and reduced heart rate from vena cava compression, thus less blood flow to the fetus). Other issues to consider are exertion at extreme environmental conditions such as excessive heights (risk of altitude sickness), so pregnant women are advised to stay below 6,000–8,000 ft and avoid being submerged under water below 30 ft (chance of decompression sickness and venous air embolism). Additionally, recreational activity involving other players (team sports) tends to have a high potential of collision or hard physical contact, which could harm both the mother and fetus, and therefore should be avoided. These athletic activities include but are not limited to soccer, basketball, and ice hockey. Similarly, the pregnant woman should abstain from athletic endeavors which carry an inherent risk of losing her balance and falling, thus causing abdominal trauma, such as downhill skiing, horseback riding, and gymnastics. Vigorous maneuvers associated with racquet sports (tennis) and impact activities such as jogging/running should be omitted as well, since these could contribute to joint damage from repetitive high loads. Additionally, pregnancy is not an ideal time to begin a vigorous exercise program or to make substantial gains in overall fitness; rather, it is a time to maintain a healthy lifestyle [151417202931].

Recommended safe and effective physical activity for the pregnant woman includes resistance training with lightweights and multiple repetitions through a dynamic range of motion to enhance muscle tone, thus adding stability and minimizing injury to the already lax ligaments and joints. Lifting techniques and positioning with weights/machines are of paramount importance in terms of safety in order to adjust to morphological changes of the pregnant body. It is also prudent not to engage in repetitive heavy or excessive isometric-type weight lifting to limit the Valsalva maneuver/pressure response in elevating systemic blood pressure excessively while exercising [134141731]. The exercise regimen should also include some sort of aerobic-type conditioning to maintain cardiorespiratory fitness. Any activity involving movement of large muscle groups in a rhythmic fashion sustained for at least 15 min will be sufficient. The ACSM–CDC guideline for intensity of aerobic exercise is moderate, equating to a brisk walking pace of 3–4 mph (3–5 metabolic equivalents (METs)) and gauged by the revised Borg’s rate of perceived exertion (RPE) between 4 and 6, with 1 being the lightest and 10 the hardest. This method is preferred since heart rate is not an accurate predictor of how hard one is working during pregnancy. The following are representative aerobic training modalities which, if followed regularly, will help in accomplishing fitness goals: walking, stationary cycling, hiking, dancing, swimming, rowing, cross-country skiing, skating, rope skipping, and indoor/outdoor group exercise classes (on land or in water). As for flexibility exercises, since the pregnant woman’s joints are already lax, she should use slow static stretches and be careful not to overstretch or perform ballistic movements in order to minimize the risk of incurring potential musculoskeletal injury [1214203031].

In short, numerous studies dealing with pregnant women participating in a regular exercise program have demonstrated substantial maternal benefits with minimal fetal risks. Positive effects include improved cardiorespiratory capacity, control of excessive weight gain and fat retention, and better mental/emotional outlook (sense of well-being). Additional beneficial effects of exercising include lessening of somatic symptoms associated with pregnancy such as insomnia, anxiety, gastrointestinal complaints, leg cramps, pelvis discomfort, and LBP. As long as standard medical guidelines are followed in terms of the “FITT” principle (frequency, intensity, type/mode, and amount of time or duration of exercise), working out during pregnancy is safe and effective in terms of maintaining health fitness for both the mother and the fetus [3121732].

17.3.5 Various Modes of Treatment for Common Musculoskeletal Injuries Sustained by Exercising While in the Pregnant State

Trauma during pregnancy is never completely avoidable, even with using preventative measures. After a traumatic episode, treatment of injured pregnant women becomes an issue due to the growing fetus. While there are different modalities to treat the pregnant female’s pain and discomfort, protection of the fetus is first and foremost, plus her symptoms may not be relieved completely despite medical management. Modification or cessation of certain activities and exercises may need to take place in order to completely carry to term without undue damage to the mother or fetus [19].

The premier treatment method of pregnancy-related musculoskeletal conditions involves avoidance of certain positions or activities which could exacerbate symptoms. The ultimate goal is to protect the injured area from further harm while enhancing mobility, strength, and endurance. Resting is the first way to treat an injury, though this is not an absolute but a relative requirement. For example, management of LBP, pelvic pain, and SI joint pain requires the pregnant woman to avoid climbing stairs, twisting, bending, and lifting maneuvers. At the same time, she should engage in a physical therapy program concentrating on spinal realignment/stabilization and balancing of the central core muscle group [4153336]. The symptomatic pregnant woman needs to concentrate on maintaining correct posture and utilizing appropriate body mechanics. Specifically, abdominal and hip/gluteal strengthening comprises a major part of the treatment strategy. Exercising the surrounding lumbar and pelvic floor musculature will also help strengthen these muscle groups to support the gravid uterus while adding to the stability of the body. Aquatic exercises are extremely beneficial in offloading joints by allowing her to continue exercising. Exercising also aids in controlling peripheral edema and helps to lower heart rate response as well, adding to the overall positive effects [2434]. Furthermore, one study had found that a combination of acupuncture and physiotherapy was more effective than therapy alone in treating pregnancy-related pelvic girdle pain [34]. Another study confirmed that an exercise program to strengthen the abdominal/hamstring muscles plus stretching the iliopsoas and paravertebral muscles was quite successful in decreasing the intensity of LBP and increasing spinal flexibility during the third trimester [37]. A third study demonstrated that physical activity prior to pregnancy reduced the risk of pelvic and LBP while being pregnant [38]. A fourth study observed that a 50 % reduction in disability did indeed occur in pregnant women engaging in a regimen composing of lumbopelvic stabilizing exercises, which continued up to 2 years postpartum [3639]. Alternatively, physical therapy programs, along with additional support such as a lumbosacral corset (nonelastic belt worn just proximal to the greater trochanter), can be beneficial in symptomatic management of low back and pelvic girdle pain plus improvement of functional status. However, another review paper found a neutral effect for both treatment modalities as far as treating similar symptoms during pregnancy [4151935].

As far as other local modalities used in treating musculoskeletal injuries related to pregnancy, most are contraindicated due to potential transfer of heat and/or transcutaneous nerve stimulation to the fetus. These methods include ultrasound, superficial heat, and electrical current. Likewise, a traction apparatus for the spine is controversial since this mechanical device may place too much pressure on the abdomen from the belt location along with adding too much tension on already lax ligaments [2]. On the other hand, local injections of an anesthetic and steroid mixture, such as for the management of de Quervain’s disease, appear to be fairly safe. However, this method also should be utilized judiciously only as an adjunctive treatment measure, along with splinting and occupational rehabilitation exercises. Administration of nonsteroidal anti-inflammatory drugs (NSAIDs) is not recommended during pregnancy due to potential fetal risk [3]. Furthermore, aspirin has been associated with intracranial hemorrhage, while the use of antiprostaglandins may result in the failure in the closure of the ductus arteriosus in the fetus, so these medications should not be utilized while pregnant [40].

17.4 Future Directions and Concluding Remarks

In summary, a pregnant woman carries with her an additional internal weight while dealing with morphological and physiological/hormonal alterations of her body. Although pregnancy may be limiting in some aspects, it need not be a condition which severely confines a woman to absolute inactivity. In fact, numerous studies have shown that working out during pregnancy is very beneficial for both the mother and the fetus. Nonetheless, certain musculoskeletal conditions do occur with or become aggravated by exercising while pregnant, but these can be treated symptomatically. Fortunately, many of these incurred problems do tend to resolve spontaneously fairly shortly after delivery, so there is no cause for extreme concern. The pregnant female, however, must take every precaution possible by modifying the manner in which she moves and exercises in order to minimize undue injury to herself and/or the fetus. By doing this, she can still maintain her body in tip-top shape in spite of anatomical and systemic changes to optimize both physical and mental health for her and ultimately benefit the baby to come!

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