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Pilates and pregnancy Exercising during pregnancy is important for maintaining muscle strength and preventing musculoskeletal problems. Adi Balogh presents the evidence that when correctly taught, Pilates may be an ideal form of exercise for achieving this. Introduction
Adi Balogh is director of the Swiss Cottage Pilates Studio, London
Pregnancy is associated with a number of musculoskeletal problems (Owens et al, 2002; Berg et al, 1988; Boissonnault and Blaschak, 1988; Wang et al, 2004). The weight and pull of the fetus, the deconditioning that results from lack of exercise and the hormonally-induced ligamentous softening leads to a significant insult to the back and associated joints. Back pain is the most common cause of physical disability in the working age population of the UK with direct healthcare costs in excess of £1.6billion (Clinical Standards Advisory Group, 1994). Even without pregnancy, most of us sit badly, stand awfully in a queue, pick up things without care and toss and twist during the night, all resulting in a lack of engagement of our postural muscles, which then become weak. While many of us think of posture as being the way we stand or hold ourselves, posture is in fact dynamic and is much more about the way we carry out functional daily activities. These postural muscles or lack of them become even more important during pregnancy. The following article is an introduction to the principles of the exercise method known as Pilates and the role that Pilates-based exercises can have on preventing a number of problems associated with pregnancy.
the more difficult exercises. Ideally, a Pilates instructor will combine mat and equipment-based exercises and tailor them to the particular user’s needs. The most commonly used piece of equipment is the reformer – a moveable carriage for pushing and pulling against spring resistance.
Problems associated with pregnancy A recent study suggested the incidence of back pain in pregnancy is over 68%, and more likely in the younger woman and those with a history of back pain. Interestingly, only 32% of the respondents in this study informed their prenatal care-providers of their back symptoms and only 25% of prenatal care-providers recommended a treatment (Wang et al, 2004). During pregnancy, certain biomechanical changes take place (see Box 1), resulting in poor posture and increased shear forces through the joints of the lower back. Because of the rise in levels of hormones such as relaxin, ligaments begin to soften, leading to loss of stability of certain joints and symphysis pubis dysfunction (Owens et al, 2002) – sacroiliac joint problems (Berg et al, 1988) are also common. In addition, many women develop symptoms of urinary incontinence (Holroyd-Leduc and Straus, 2004) during pregnancy.
Breast and chest What is Pilates? Pilates is a ‘mind-body’ conditioning exercise programme that targets the muscles stabilising the trunk (Anderson and Spector, 2000). The method was the brainchild of Joseph Hubertus Pilates. Born in Germany in 1880, Pilates was a rather sickly child and said to have asthma, rickets and rheumatic fever. However, by the age of 14 he had overcome his illnesses and chose to dedicate his life to physical fitness. He studied a variety of techniques from gymnastics, zen meditation, martial arts and yoga to the Greek and Roman regimes of exercise. These were the inspiration for his method that he called ‘contrology’. After the first World War, he emigrated to the US and opened the first Pilates studio in New York City. Dancers and other performing artists took a liking to his techniques and it gained an almost cult-like status among these groups. Following a great deal of research to understand the science behind the art (Hodges and Richardson, 1997; Richardson et al, 2002), the Pilates method has now become a mainstream form of exercise used by doctors, physiotherapists and physical therapists all over the world. Pilates first described 34 mat-based exercises, although he also introduced moving equipment that worked on a pulley and spring principal to aid beginners with some of
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The increased size and weight of the breasts causes the pectoralis minor muscle to shorten and tighten, intensified further by bad posture and poor feeding positions. This causes increased stress to the spine, leading to neck and shoulder ache.
Box 1. Biomechanical changes of pregnancy Centre of gravity moves forward Muscles tighten and shorten: ■ Pectorals ■ Iliopsoas ■ Hamstrings ■ Lumbar extensors. Muscles lengthen and weaken: ■ Rectus abdominus ■ Gluteals. Posture changes: ■ Increased lumbar lordosis ■ Increased thoracic kyphosis. Pressure on pelvic floor muscles increases Rib cage flares upwards
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Wellbeing Learning to engage the transverses This breathing technique utilises four sets of A correctly fitting bra is essential to prevent abdominus and perform the exercises muscles, namely, the diaphragm, the transover-stretching of the breast tissues and correctly is not something that can be learnt verses abdominus (inner abdominal muscle), provide support to the spine. Wider shoulder from a book or video. Therefore, it is multifidus (part of the erector spinae straps help distribute weight evenly over the recommended that mothers who suffer from muscles) and the pelvic floor muscles. These shoulders. Sports bras are recommended for this condition are referred early to a muscles have been termed the ‘cylinder of exercising to help reduce bouncing of the physiotherapist or Pilates specialist for onestability’ and contracting them together leads already tender and sore breasts. It is worth to an increased intra-abdominal pressure. recommending that clients see a bra specialist to-one tuition in the first instance. This tenses the thoracolumbar fascia and has to ensure their bra is been proposed to be one mechanism of correctly sized and Pelvic floor increasing the stability of the lumbar spine fitted. Overly tight Pelvic floor muscles region (Hodges and Richardson, 1997). bras can compress play an important Learning the correct method of breathing the breasts and chest part in our pelvicis vital, but one of the most difficult wall and may lead to spinal stability, principles for beginners to grasp. Once shallow breathing. but have other the mother has stabilised her pelvis and Diaphragmatic important functions, lumbar spine, gradual arm and leg breathing provides a such as supporting A mother and her baby taking part in a Pilates class movements are introduced to challenge this connection that the pelvic organs and transmits forces ensuring resistance to core stability. Exercise during pregnancy offers many efficiently throughout the entire body. Such sudden rises of intra-abdominal pressure physical and emotional benefits (Artal and (lateral chest) breathing is one of the (during sneezing and coughing) and control O’Toole, 2003) and because of the gentle fundamental principles of Pilates and can of continence. nature of many of the exercises in Pilates, it is help the mother relax and open up the After birth, the pelvic floor muscles have increasingly being sought by mothers during chest wall wider to give more space for the the ability to be retrained. When the and after pregnancy. In particular, many of growing fetus. individual starts the retraining of pelvic floor the exercises can be performed on the side or muscles, it is important first to identify and while sitting, and hence are safe during the isolate the correct muscles. In the Pilates Abdominal muscles second and third trimester when a supine studio, we start this process in positions Poor functional use of the abdominal wall position is contraindicated. where there is the lowest load on the pelvic reduces stability in the lower back and pelvic Pilates is now a mainstream exercise and floor muscle, such as side-lying or supine area. The abdominal muscles undergo a great positions and progress to seated and standing although the basis for the exercises have been amount of stretch in all directions during well researched (Hodges and Richardson, exercises thereafter. Mothers are then pregnancy. As the waistline increases, the two 1997; Richardson et al, 2002), very little has encouraged to incorporate their exercises bands of recti muscles can stretch away from been published on Pilates in the academic the midline (linea alba) to allow more space for into their daily functional activities. literature, largely as a result of Pilates Pelvic floor exercises should ideally be the expanding uterus. This is known as activities being performed throughdiastasis recti and occurs in up to two-thirds of outside of academic women during their second and third trimester out pregnancy, institutions. I am although if a women (Boissonnault and Blashchak, 1988). This can unaware of any has not been add to chronic backache due to decreased published studies educated during the support from the abdominal muscles. looking at the effects antenatal period, then If midwives see a case of diastasis recti, it of Pilates on she must begin as is inadvisable to simply prescribe stomach pregnancy or indeed soon as possible after strengthening exercises, because they can whether exercises birth. If she does not, actually make the problem worse through to focus on the the muscles remain doming. Doming is a condition whereby the Women concentrate on an equipment-based Pilates exercise transverses stretched and abdominal contents herniate through the abdominus during weakened and weakened abdominal wall during exercise. pregnancy can reduce the incidence of recovery is prolonged. Pilates-based exercises try to avoid diastasis recti. Such studies are therefore strengthening the rectus abdominus and much needed. oblique muscles, which can cause the two Pilates in pregnancy In the hands of the right instructor, Pilates recti muscles to pull away further from the The Pilates method emphasises the can be enjoyable and a highly effective form midline, making it even harder to correct. importance of beginning movements from a of therapy. It is important to caveat this by Pilates puts importance on activating the central core of stability, combined with saying that Pilates in the UK is not well deep postural muscles, in particular, appropriate breathing control. Pilates governed, and it is therefore important that transverses abdominus. This avoids doming focuses on lateral chest breathing as opposed anyone considering seeing a therapist check and so less strain is put across the diastasis. to the stomach breathing advocated in yoga.
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important for the mother’s physical and mental wellbeing – she looks after her baby’s body for nine months, who cares for hers?
Summary
research bursary
Pregnancy is associated with a number of musculosketal problems. It is important to educate all mothers, as well as those involved in ante- and postnatal care with advice on bras and exercises that are safe in pregnancy (in particular pelvic floor exercises). There is not much that can be done to alter the inevitable physiological and hormonal changes of pregnancy. However, by strengthening the core stabilising muscles around the pelvis and spine, and improving the breathing pattern, it is hoped that one can optimise the body for the challenges it may face. Pilates is based on the principle that a central core is developed and then movements are introduced to challenge this core stability. This philosophy is clearly applicable in pregnancy – a significant test both mentally and physically on the mother’s body. By maximising the mother’s core stability before and during pregnancy, it should be possible to limit any potential harm. Returning to exercise soon after the birth is
Further information The Swiss Pilates Studio in Swiss Cottage, London, runs ante- and postnatal Pilates classes for a maximum of four mothers at a time. For more information, please contact the author via email:
[email protected]
References Anderson BD, Spector A. (2000) Introduction to Pilates-based rehabilitation. Orthopedic Physical Therapy Clinics of North America 9(3): 395-410. Artal R, O’Toole M. (2003) Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. British Journal of Sports Medicine 37(1): 6-12. Berg G, Hammar M, Moller-Nielsen J, Linden U, Thorblad J. (1988) Low back pain during pregnancy. Obstetrics and Gynecology 71(1): 71-5. Boissonnault JS, Blaschak MJ. (1988) Incidence of diastasis recti abdominis during the childbearing year. Physical Therapy 68(7): 1082-6. Clinical Standards Advisory Group. (1994)
Epidemiology review: the epidemiology and cost of back pain. HMSO: London. Hodges PW, Richardson CA. (1997) Contraction of the abdominal muscles associated with movement of the lower limb. Physical Therapy 77(2): 132-42. Holroyd-Leduc JM, Straus SE. (2004) Management of urinary incontinence in women: scientific review. Journal of the American Medical Association 291(8): 986-95. Morkved S, Salvesen KA, Bo K, Eik-Nes S. (2004) Pelvic floor muscle strength and thickness in continent and incontinent nulliparous pregnant women. International Urogynecology Journal and Pelvic Floor Dysfunction 15(6): 384-9. Owens K, Pearson A, Mason G. (2002) Symphysis pubis dysfunction – a cause of significant obstetric morbidity. European Journal of Obstetrics, Gynecology and Reproductive Biology 105(2): 143-6. Richardson CA, Snijders CJ, Hides JA, Damen L, Pas MS, Storm J. (2002) The relation between the transversus abdominis muscles, sacroiliac joint mechanics and low back pain. Spine 27(4): 399-405. Wang SM, Dezinno P, Maranets I, Berman MR, Caldwell-Andrews AA, Kain ZN. (2004) Low back pain during pregnancy: prevalence, risk factors, and outcomes. Obstetrics and Gynecology 104(1): 65-70.
The Royal College of Midwives Learning, research and practice development department
Ruth Davies research bursary Are you longing to undertake or in the process of doing a piece of research, but short of funds? A bursary has been made available to the RCM to support midwives, through the financial support of the Liverpool Victoria Group. Successful applicants will each receive £5000 to assist with their research. The purpose of the bursary is to: ■ ■ ■ ■ ■ ■
Support the RCM objective of building and strengthening a research culture among midwives Enable the RCM to increase the research profile of midwives nationally and internationally Enable midwives to further develop their research knowledge and skills Build the capacity of midwives to use research in their clinical practice Add to the body of knowledge of midwifery practice Develop the research network for midwives providing a forum to develop and discuss research.
Who is eligible to apply? Practising midwives who are RCM members, midwives with basic knowledge, skills and understanding of the research process, who have access to research support in their Trust or higher education institution and who have been in practice for two years or more.
Application details are now available and the closing date is 5pm on 22 July. For more information, please contact Marlyn Gennace at the RCM, 15 Mansfield Street, London, W1G 9NH or email:
[email protected] Please include your full postal address.
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