Other Systems 2 Pt. 1

Pregnancy Questions/Themes - What are things to consider with:

• system interactions in pregnancy

• sidelying in pregnancy

• pregnancy complications

  • other conditions?

• pregnancy exercises

• system interactions in pregnancy

  • postural changes

  • HR and BP changes

• sidelying in pregnancy

  • left sidelying

  • avoid supine hypotensive syndrome

• pregnancy complications

  • preeclampsia vs. eclampsia

• pregnancy exercises

  • posture

  • precautions

Changes with pregnancy:

What is essential weight gain and for what?

• 25-35 lbs. essential for baby’s nourishment

Changes with pregnancy - MSK System:

• postural changes? (4)

• how long does postural stress continue for and due to what?

• postural changes

  • forward head, kyphosis, increased lordosis, anterior pelvic tilt - COM goes anterior

• postural stress continues even postpartum due to lifting and carrying of baby

Treatment for MSK changes (4)

1. postural education

2. stretching of tight muscles and strengthening of weaker ones

3. pelvic stabilization exercises - bc increase in relaxin = ligamentous laxity

4. pelvic tilts

Cardiovascular changes in pregnancy:

• what happens to the blood pressure and when?

• what happens to cardiac output?

• after 4 months, what complications can be caused with supine lying after 5 minutes?

  • this declines CO and may cause what?

  • therefore, no supine lying when?

• both systolic and diastolic BP is low/reduces in the first and second trimesters, increases in the last trimester

• CO increases due to increased blood volume

• supine-lying after 4 months = compression of inferior vena cava

Cardiovascular changes in pregnancy:

• what happens to resting HR? what is the change during exercise?

• resting HR increases by 10-20 bpm, but max HR does not increase proportionally with exercise

  • since resting HR is high, it does not increase more like the general population with exercise

What is the best position for pregnancy?

• this position:

  • decreases compression of what?

  • maximizes what?

  • decreases GERD how?

  • improves what circulation?

• decreases compression of inferior vena cava

• maximizes cardiac output

• decreases GERD as internal organs are relaxed

• improves maternal and fetal circulation

Recap of changes or system interactions during pregnancy:

• MSK

• CV

• pulmonary

  • depth of respiration, respiration rate, tidal volume, work of breathing

• metabolism

• MSK

  • changes in posture (kyphosis), ligamentous laxity, LBP, teach stabilization and postural education

• CV

  • changes in blood volume, HR, CO

• pulmonary

  • increased depth of respiration, respiration rate stays the same, tidal volume increases, work of breathing increases (diaphragm is elevated, changes of rib position)

• metabolism

  • increases bc of the fetus

Practice Question 1.1 – Previous Class Warm Up!

What is the BEST initial physical therapy intervention?

A. Supine and perform contractions held for 3 seconds each

B. Left side lying and perform contractions held for 5 seconds each

C. Right side lying and perform contractions held for 5 seconds each

D. Sitting and perform contractions held for 10 seconds each

B. Left side lying and perform contractions held for 5 seconds each

RATIONALE: Left side lying is the most appropriate position to start pelvic floor muscle strengthening as the patient is pregnant. Supine position causes compression of Inferior vena cava causing supine hypotensive syndrome. Sitting is anti gravity, and not recommended initially.

• strengthen levator ani

• supine increases inferior vena cava compression

Practice Question 1.2 – System Interactions

Which of the following is MOST APPROPRIATE regarding physiological changes related to pregnancy?

A. Blood pressure increases in first and second trimester, and then decreases in the third trimester

B. Cardiac output is decreased in pregnancy

C. Resting heart rate is decreased during pregnancy

D. Metabolic rate and heat production increases during pregnancy

D. Metabolic rate and heat production increases during pregnancy

RATIONALE: Resting HR is increased during pregnancy. Blood pressure decreases in first and second trimester and then increases in the third trimester. Metabolic rate and heat production increases during pregnancy. Cardiac output is increased in pregnancy.

for pregnant women, usually fasting blood glucose decreases so when they wake up, FBG drops and fetus needs nourishment too

both eclampsia and preeclampsia are considered 911 situations right? Yes

Describe what and when preeclampsia takes place.

• what changes in urine, reflexes, fluid, and 2 other symptoms?

• what value is the BP reading?

  • what would confirm the diagnosis?

how severe is this?

• pregnancy induced hypertension after the 20th week of gestation (bc BP normally increases in third trimester)

• increase in protein in urine, hyperreflexia, edema, headache, sudden weight gain

• a blood pressure reading more than 140/90 mmHg

  • second abnormal blood pressure reading four hours after the first confirms the diagnosis

• EMERGENCY

Practice Question 1.3 – Pregnancy Complications

After an uncomplicated vaginal delivery of her child, patient is seen again for physical therapy. During the treatment, the patient begins to report headache with visual disturbances then suddenly develops a seizure. Which condition is MOST LIKELY seen in this patient?

A. Preeclampsia

B. Gestational diabetes

C. Eclampsia

D. Ectopic pregnancy

C. Eclampsia

RATIONALE: Eclampsia is a characterized by seizures, headaches, visual disturbances after pregnancy. more severe

Preeclampsia can progress to eclampsia, but eclampsia does not need preeclampsia to occur. preeclampsia does NOT have seizures

gestational diabetes = increased BG during pregnancy

• during pregnancy, for some people, the body stops producing insulin so blood glucose increases

• resolves after delivery

ectopic pregnancy = fertilization of the egg outside of the uterus/uterine cavity

• can happen in fallopian tubes - not safe for pt due to LBP/pelvic pain, discomfort, vaginal bleeding

Contraindications to exercise pt. 1:

• hemodynamically significant heart disease, meaning?

• cardiopulm disease?

• incompetent cervix meaning?

• vaginal bleeding especially when?

• placentia previa when? (explain this)

• hemodynamically significant heart disease, meaning?

  • acute signs of significant heart failure / irregular pulse

• cardiopulm disease?

  • restrictive lung disease

• incompetent cervix meaning?

  • early dilation of cervix before full term

• vaginal bleeding especially when?

  • second or third trimester

• placentia previa when? (explain this)

  • after 26 weeks gestation

  • placenta is located on the uterus position in which it may detach before the baby is delivered

Contraindications to exercise pt. 2:

• which pregnancy condition?

• if they had rupture of membranes why?

• premature labor when?

• pancreas disease?

• blood cell issue?

recall what is the safe range for RPE

• which pregnancy condition?

  • preeclampsia/pregnancy-induced hypertension

• if they had rupture of membranes why?

  • loss of amniotic fluid before the onset of labor

  • this fluid is important for nourishing the baby

• premature labor when?

  • labor before 37th week of pregnancy

• pancreas disease?

  • maternal type I diabetes

• blood cell issue?

  • severe anemia

RPE 11-13; during pregnancy exercise as tolerated

Practice Question 2 – Pregnancy Exercises

A patient, after an uncomplicated delivery, has a 3-cm diastasis recti and weak abdominal muscles. Which of the following exercises is MOST APPROPRIATE for initial phase of rehabilitation?

A. Modified Plank exercises on forearms and knees

B. Head lifts with arms bracing the abdomen

C. Curl-ups with hands behind the head

D. Deep breathing exercises in bridging position

B. Head lifts with arms bracing the abdomen

RATIONALE: A split >2 cm requires bracing/ splinting of the abdomen while performing the head lift exercises. Once the patient has improved core stability and the diastasis recti has begun to heal, more challenging exercises such as modified plank exercises or curl-ups can be introduced, but initially, exercises should prioritize safety and gentle engagement of the core muscles.

review: diastasis recti = separation of rectus abdominis muscle from the linea alba

assess this by positioning them hooklying, keep fingers horizontally over the umbilicus - ask the pt to perform a curl up with clearance of the scapula then see how many fingers go inside the umbilicus

• 2 fingers = 2 cm

• significant = diastasis recti > 2cm

Treatment for diastasis recti pt. 1:

• head lift

  • pt is in what position and does what for support?

  • have pt exhale and lift what? while at the same time, using their hands to gently approximate what?

  • then lower the head slowly and?

• head lift

  • pt is in hooklying position and crosses arms around the stomach area for support

  • have pt exhale and lift only the head off the floor, while at the same time, using their hands to gently approximate the rectus muscles toward midline

  • then lower the head slowly and relax

Treatment for diastasis recti pt. 2:

• head lift with pelvic tilt

  • pt is in what position?

  • how do they self-support their body?

  • have patient slowly lift what while approximating the rectus muscles and perform what?

  • then lastly slowly do what?

• head lift with pelvic tilt

  • pt is in hooklying

  • arms are crossed over the diastasis for support as described in head lift exercise

  • have patient slowly lift only the head off the floor while approximating the rectus muscles and perform a posterior pelvic tilt

  • then lastly slowly lower the head and relax

Treatment for diastasis recti:

• how should all abdominal contractions be performed?

• what is the progression of treatment?

  • what is the FF tip to remember?

  • what if 3-4 cm?

  • what if it is >4cm?

  • if >6cm?

• perform all abdominal contractions with an exhalation (during concentric) to minimize intra-abdominal pressure

• abdominal bracing —> + head lifts —> + posterior pelvic tilt

• 3-4 cm = bracing + head lifts

• if >4cm, no head lift, just bracing and breathing

• >6cm refer pt and physician will decide if they want to do surgery or conservative

NPTE vs. treatment now for diastasis recti

• NPTE

  • diastasis recti

    • avoid crunches, double leg lifts, fire hydrant (dog peeing), avoid valsava maneuver

• clinical research

  • can do some advanced exercises

Genitourinary Quick Recap!

• Treatment for functional incontinence?

• What type of incontinence is seen with diabetes mellitus?

• Blood pressure changes in pregnancy?

• Exercises to avoid with diastasis recti?

• Treatment for functional incontinence?

  • clear the clutter

  • if pt has cognitive problem then prompt with post-its

  • if they have weakness, do strengthening

  • gait problems, do gait training

• What type of incontinence is seen with diabetes mellitus?

  • overflow

• Blood pressure changes in pregnancy?

  • decreases first/second trimester

  • increases third trimester

• Exercises to avoid with diastasis recti?

  • crunches, double leg lifts, fire hydrants, valsava maneuver

Gastroesophageal Reflux Disease (GERD): reflux of gastric content from where into where?

what are 3 complications?

• reflux of gastric content from gastroduodenal contents into the esophagus

  • aka lower esophageal dysfunction because it does not stay closed so gastric contents comes up

• complications (if GERD is not taken care of)

  • aspiration pneumonia, asthma

  • esophagitis (can be pre-cancer)

GERD symptoms:

• heart burn occurring when? (2)

• swallowing?

• sour taste from what?

• voice?

• atypical pain where? (2)

what is this confused with?

• heart burn

  • 30 minutes after eating

  • at night lying down

• dysphagia

• sour taste

  • from regurgitation of acids

• hoarseness of voice

• atypical pain

  • head and neck, chest

confused with angina when they have chest pain

How would you differentiate whether GERD symptoms is a GI or cardiac issue?

• position of pt

  • GI = improves with change of position

  • cardiac = worsen with activity

• antacids

  • GI = improves

  • cardiac = does not relieve

Practice Question 3 – GERD

Which of the following guidelines is MOST APPROPRIATE in treating patients with gastroesophageal reflux disease?

A. Exercises should be performed in supine position

B. Encourage the patient to sleep on right side to prevent nocturnal reflex

C. Instruct the patient to perform Valsalva maneuvers during exercise

D. Encourage the patient to elevate the head of the bed while lying down

D. Encourage the patient to elevate the head of the bed while lying down

RATIONALE: Elevating the head of the bed reduces nocturnal reflux by using gravity to minimize backflow of gastric contents into the esophagus. Sleep on left side is encouraged to prevent nocturnal reflex, L side relaxes internal organs. Exercise must be completed 2-3 hours after eating. Valsalva maneuver increases intra-abdominal pressure, which worsens reflux symptoms.

when should the patient perform valsalva maneuver? if they are a spinal cord injury and need help fully voiding

Treatment of GERD:

• maintain what positions?

• eat meals how much longer before sleep?

• avoid what position and why?

• sleep on what side and why?

• maintain upright positions

• eat meals at least 3-4 hours before sleep

• avoid supine - tends to straighten the esophagus

• sleep on L side to prevent nocturnal reflex

Treatment of GERD pt. 2:

• exercise when before or after meals?

• avoid what 4 types of food?

• 3 types of drugs?

• exercise must be completed 2-3 hours after eating or before meals

• avoid spicy, chocolate, fatty food, peppermint

• drugs

  • antacids

  • H2 receptor blockers

  • protein pump inhibitors