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.

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.

Midwives magazine: May 2005

 

Introduction

 

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.

 

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 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  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

 

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.A correctly fitting bra is essential to prevent over-stretching of the breast tissues and provide support to the spine.

 

Wider shoulder straps help distribute weight evenly over the shoulders. Sports bras are recommended for exercising to help reduce bouncing of the already tender and sore breasts. It is worth recommending that clients see a bra specialist to ensure their bra is correctly sized and fitted. Overly tight bras can compress the breasts and chest wall and may lead to shallow breathing. Diaphragmatic breathing provides a connection that transmits forces efficiently throughout the entire body. Such (lateral chest) breathing is one of the fundamental principles of Pilates and can help the mother relax and open up the chest wall wider to give more space for the growing fetus.

 

Abdominal muscles

 

Poor functional use of the abdominal wall reduces stability in the lower back and pelvic area. The abdominal muscles undergo a great amount of stretch in all directions during pregnancy. As the waistline increases, the two bands of recti muscles can stretch away from the midline (linea alba) to allow more space for the expanding uterus. This is known as diastasis recti and occurs in up to two-thirds of women during their second and third trimester (Boissonnault and Blashchak, 1988). This can add to chronic backache due to decreased support from the abdominal muscles. If midwives see a case of diastasis recti, it is inadvisable to simply prescribe stomach strengthening exercises, because they can actually make the problem worse through doming. Doming is a condition whereby the abdominal contents herniate through the weakened abdominal wall during exercise. Pilates-based exercises try to avoid strengthening the rectus abdominus and oblique muscles, which can cause the two recti muscles to pull away further from the midline, making it even harder to correct.

 

Pilates puts importance on activating the deep postural muscles, in particular, transverses abdominus. This avoids doming and so less strain is put across the diastasis. Learning to engage the transverses abdominus and perform the exercises correctly is not something that can be learnt from a book or video. Therefore, it is recommended that mothers who suffer from this condition are referred early to a physiotherapist or Pilates specialist for oneto- one tuition in the first instance.

 

Pelvic floor

 

Pelvic floor muscles play an important part in our pelvicspinal stability, but have other important functions, such as supporting the pelvic organs and ensuring resistance to sudden rises of intra-abdominal pressure (during sneezing and coughing) and control of continence. After birth, the pelvic floor muscles have the ability to be retrained. When the individual starts the retraining of pelvic floor muscles, it is important first to identify and isolate the correct muscles. In the Pilates studio, we start this process in positions where there is the lowest load on the pelvic floor muscle, such as side-lying or supine positions and progress to seated and standing exercises thereafter.

 

Mothers are then encouraged to incorporate their exercises into their daily functional activities. Pelvic floor exercises should ideally be performed throughout pregnancy, although if a women has not been educated during the antenatal period, then she must begin as soon as possible after birth. If she does not, the muscles remain stretched and weakened and recovery is prolonged.

 

Pilates in pregnancy

 

The Pilates method emphasises the importance of beginning movements from a central core of stability, combined with appropriate breathing control. Pilates focuses on lateral chest breathing as opposed to the stomach breathing advocated in yoga. This breathing technique utilises four sets of muscles, namely, the diaphragm, the transverses abdominus (inner abdominal muscle), multifidus (part of the erector spinae muscles) and the pelvic floor muscles. These muscles have been termed the ‘cylinder of stability’ and contracting them together leads to an increased intra-abdominal pressure.

 

This tenses the thoracolumbar fascia and has been proposed to be one mechanism of increasing the stability of the lumbar spine region (Hodges and Richardson, 1997). Learning the correct method of breathing is vital, but one of the most difficult principles for beginners to grasp. Once the mother has stabilised her pelvis and lumbar spine, gradual arm and leg movements are introduced to challenge this core stability. Exercise during pregnancy offers many physical and emotional benefits (Artal and O’Toole, 2003) and because of the gentle nature of many of the exercises in Pilates, it is increasingly being sought by mothers during and after pregnancy. In particular, many of the exercises can be performed on the side or while sitting, and hence are safe during the second and third trimester when a supine position is contraindicated.

 

Pilates is now a mainstream exercise and although the basis for the exercises have been well researched (Hodges and Richardson, 1997; Richardson et al, 2002), very little has been published on Pilates in the academic literature, largely as a result of Pilates activities being outside of academic institutions. I am unaware of any published studies looking at the effects of Pilates on pregnancy or indeed whether exercises to focus on the transverses abdominus during pregnancy can reduce the incidence of diastasis recti. Such studies are therefore much needed. In the hands of the right instructor, Pilates can be enjoyable and a highly effective form of therapy. It is important to caveat this by saying that Pilates in the UK is not well governed, and it is therefore important that anyone considering seeing a therapist check their credentials carefully and preferably seek references from other patients.

 

Summary

 

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 important for the mother’s physical and mental wellbeing – she looks after her baby’s body for nine months, who cares for hers?

 

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: adi@swisspilates.com

 

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.