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Pilates On Call: Working With Pregnant and Postpartum Clients

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Amanda Martin

Debra GoodmanFor the fourth installment of our Pilates On Call series, we’re focusing on the topic of pregnancy. We’re sure it will be a busy and popular post, if site traffic for this topic is any indicator.

Pilates On Call is a month-long, open Q&A session with an expert, so this is your opportunity to ask about the finer points of Pilates exercise with this population. Perhaps you’d like advice for working with a newly pregnant client, or information about a particular pregnancy-related condition.

We’re thrilled to welcome Debra Goodman, MSPT, back to the site. She’s written several popular articles on Pilates and pregnancy for us, and has an extensive background treating pregnant and postpartum patients; she is one of few physical therapists trained in internal evaluation and treatment of the pelvic floor muscles. And we’re equally thrilled to introduce Amanda Martin, owner of balance in Athens, Georgia, a Pilates and wellness studio that specializes in working with pregnant and post-natal clientele, among other populations. She has been doing this kind of Pilates work since 2004.

Post your questions in the comments section below or email them to us editor@pilates-pro.com. Debra and Amanda will get to them as quickly as possible, but might need a day or two to respond.

More About Debra
Debra Goodman MSPT, is a licensed manual physical therapist with specialties in women’s health, dance medicine and sports medicine. She has been a physical therapist for Westside Dance Physical Therapy, New York City Ballet and the School of American Ballet. Debbi also had a women’s health/orthopedic-focused private practice in New York City. She now practices in Albany, where she’s lived since 2004. She is one of the few physical therapists trained in internal evaluation and treatment of the pelvic floor muscles. She is skilled in the treatment of pregnancy and postpartum problems including chronic pain, sciatica, cesarean-section recovery, urinary incontinence, and post-delivery scars. Debra is a Pilates instructor and part of the continuing education faculty for Kinected and The Kane School of Core Integration in New York City.

More About Amanda
Amanda Martin owns b a l a n c e, a pilates and wellness studio in Athens, Georgia, and has been specializing in pre- and post-natal Pilates since 2004. She trained with Debra Goodman, MSPT, learning techniques to address musculoskeletal changes, minimize abdominal muscle separation and restore the health of the pelvic floor. Amanda received her Pilates teaching certificate at the Kane School of Core Integration, where she later worked as an expert teacher. She continues to study with Kuan Hui Chew and her mentor Madeline Black. Amanda was co-owner of Indigo, a Pilates studio in Brooklyn, from 2005 to late 2008 before she headed back home to the South.

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RELATED ARTICLES
Pilates and Pregnancy: Safe Ab Exercises
The Pilates Bookshelf: Top Pregnancy Resources
Postpartum Recovery: Helping New Moms Get Their Bodies Back
The Pilates Push

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Reader Comments (19)

I'm currently working with a newly pregnant client. She's been very fit and active in the previous year we've worked together and loves to be challenged in our at-home mat sessions (we use lots of props: therabands, foam rollers, weighted balls, pilates ring, Pilates Stick). I want to continue to challenge her throughout the pregnancy, but am somewhat nervous about giving her workouts that might be too strenuous or include exercises not conducive to the many changes her body will be going through. Would love some new and creative suggestions. THANKS!!

Hi Michael,

You should be able to continue with your client’s regular workout if she feels up to it. As her body changes, encourage her to give you regular feedback. You will need to modify her workout if she feels tired or nauseous or achy. You’ll also need to make sure she doesn’t get overheated. A nice way to do that is to stop for water every 15 minutes.

Here are a few things to note:
* During the first trimester you should still be able to work in supine positions as long as your client is comfortable.
* Be careful not to overstretch the adductors as the pubis becomes unstable from the relaxin hormone present during pregnancy—no “butterfly” stretch.
* As your client’s belly grows you will need to modify any exercise where the transversus abdominis contraction cannot be maintained. When the transversus is weak the rectus abdominis muscle will “bulge” and this added pressure can cause the rectus to separate. (Keep that in mind if you’re using your Pilates Stick for Rolldown.)
* Exercises with double leg lifts/lowering should be avoided. They put too much strain on the abdominals and can increase pelvic pain.

You’ve got a great array of props but if you are looking for new ideas, I’d suggest an Overball, a squishy ball that can be quickly inflated and deflated on the spot. A semi-deflated overball can be added under the head during many supine exercises to help strengthen the multifidi, especially when your client gets to the point that prone exercises are no longer an option. It can also more comfortable than a roller when working on thoracic arching. Both exercises are good for addressing postural changes that occur during pregnancy. (You can see the overball here http://www.optp.com/Soft-Gym-Overball__LE9509.aspx)

The stability ball is also a great prop to have. It’s useful during each stage of pregnancy, as your client’s needs change. You can use it now for bridging, squats, wall push-ups (standing with hands on ball at the wall) or sit on it to do theraband/arm exercises. Sitting on the ball will challenge her balance and give her good feedback for engaging the pelvic floor. As her belly grows she may opt for a modified workout—simple pelvic tilts and hip circles on the ball will feel good for releasing lower back tension in addition to strengthening the abs and pelvic floor. Some of my clients have even used the stability ball during labor. Many sit on it to rock a newborn to sleep.

I also use yoga bolsters to prop clients when long periods of supine lying are no longer advised. If you have two of them place them in a “T” position and have your client propped for arm exercises, pelvic tilts, bridging, knee folds and cervical nod/curl. You can also get a similar effect with pillows and blankets.

Good luck!
Amanda

February 3, 2010 | Unregistered CommenterMichael T

I would like to know which exercises a pregnant woman can't do because they are high impact on the baby. I also have another question: Is a newly pregnant woman always able to do Pilates? Or is it better to wait two or three months?

Hi Bernadette,

A prenatal Pilates program should address the musculoskeletal imbalances of the changing pregnant body and should emphasize abdominal and pelvic floor strengthening. Everybody is different and every pregnancy is different, so be sensitive to your client's needs and encourage her to give you feedback on how she’s feeling. (I have to admit that I’m not sure what you mean by “high impact”—I’m a little stumped by that!)

You might want to take a look at Debbi's article, Pilates and Pregnancy: Safe Ab Exercises. Also take a look at the notes I included in response to Michael's question, in asterisks, just above this one. Those are some basic guidelines to follow. Always make sure your client is comfortable, adding pillows or blankets to prop the belly when doing side-lying exercises.

As far as being newly pregnant goes, a regular client should be able to continue with her routine as long as she feels up to it. If you have a client new to Pilates, a beginner program that emphasizes breathing, abdominal and pelvic- floor strengthening and gentle stretching will be a safe way to start.

Hope that helps!
Amanda

February 3, 2010 | Unregistered CommenterBernadette

Can you please discuss diastasis and which mat exercises you would skip or how you would alter them. What are the best reference sources for further reading on Pilates and pregnancy?

Hi Rachel,

Just wanted to call attention to a couple of articles Debra has already written for us that should help with your questions. They are all linked in the main post above, under the 'Related Articles' heading. She includes a discussion of diastasis and provides a sample prenatal mat workout in Pilates and Pregnancy: Safe Ab Exercises. She also compiled The Pilates Bookshelf: Top Pregnancy Resources, which should be self-explanatory : ) Hopefully, it'll be easier for everyone to locate them now that I've added those links in a more obvious spot. Thanks for writing!

Best,
Lauren/Editor

February 3, 2010 | Unregistered CommenterRachel

I am a Pilates teacher and currently pregnant. I did Pilates on the reformer my entire pregnancy (up to 39 weeks). I'm in my last week and have not done it this week due to being tired and feeling as if my rib cage is about to separate apart - what is this from? The exercises I noticed I could not do are flexion, single leg bridging, large leg movements, and excessive adduction or abduction exercises. As I near having the birth of my child, what do you teach to a post-natal client? I have heard kegels can start immediately albeit slowly. I have also read that flexion should start slowly obviously and that flexion with rotation is better to start with. Any other suggestions would be greatly appreciated for my own exercise and that of my clients.


Hi Jeffy,

The rib cage actually increases in diameter several centimeters during the course of the pregnancy. By the end of the pregnancy, the fetus and uterus have expanded into the abdominal cavity putting pressure on the rib cage.

Flexion is a movement, not an exercise. Flexion movements in general tend to be less comfortable as the pregnancy progresses due to the growth of the fetus/uterus into the abdominal cavity. Later on, flexion causes compression of the anterior diaphragm and the fundus of the uterus, which is not comfortable. Flexion movements also are not functional as the thoracic spine is becoming more kyphotic, and flexion tends to support that posture.

The difficulty with the leg exercises are due to hypermobility of the pelvis that occurs during pregnancy. Many pregnant women are uncomfortable doing any kind of abduction, adduction, or large leg movements due to excessive torque on the sacroiliac joints.

Postpartum, women should begin with neutral spine core stability work and kegels. TVA strengthening is extremely important. Emphasis should be placed on closing the diastasis. See my Safe Abs and Postpartum Recovery articles for more insight.

Thanks!
Debbi

February 3, 2010 | Unregistered CommenterJeffy Pellman

It would be so helpful to see a list of exercises that are generally appropriate for prenatal clients on the various apparatus and any modifications. I am currently teaching prenatal clients occasionally, and I feel my repetoire of exercises for them is limited. Any suggestions would be much appreciated. Thank you!

February 4, 2010 | Unregistered CommenterAL

Yes pls! A list of exercises that are generally appropriate for pregnant clients on the various apparatus, as well as any modifications. Thank you!

Hi. This is for AL, Anne and Lubna.

I have to admit I have reservations about giving you a list of exercises. For one, we may have different names for these exercises. More importantly, there is no substitute for a great education in the area of prenatal and postpartum Pilates. I hope this gives you some ideas but I want to encourage you to take control of your learning and seek out workshops and continuing education classes, especially since Pilates is growing in popularity for this population. (In fact, Debbi has a workshop coming up at the end of May, if you’re in the New York area.)

I hope you’ve already noted the basic guidelines we established in previous answers. Here’s a quick review:
*Avoid exercises with double leg lifts or lowers
*Don’t overstretch the adductors
*Avoid exercises where the transversus engagement cannot be maintained
*Avoid prolonged periods in the supine position

Given those guidelines, here are some ideas that have worked for my clients. Remember that when you get to the point that you need to modify supine exercises, you can use blankets and pillows to prop a client or use two bolsters in a “T” position.

REFORMER: Footwork can be done seated on the short box but I tend to do it with the bolsters in a “T” position and adjust the footbar to make the position comfortable for them. Sleeper (sidelying “footwork” with the top leg on the footbar) is also great for working the hip stabilizers. I skip Supine Arm Circles after the first trimester because it’s too challenging to keep the transversus engaged--the legs are both lifted. Fortunately there is no shortage of exercises for the arms. Facing the back of the reformer you can do Biceps Curls, Tricep Press, Chest Expansion, Rowing variations, etc. Facing the front, try: Offering, Salute, Hug a tree, Front Rowing, etc. During the advanced stages of pregnancy, clients may feel more comfortable sitting on the short box while doing these arm exercises as it gives the belly more room.

TRAPEZE TABLE (CADILLAC): I tend to use the Cadillac for Supine/Sidelying Leg Spring Series depending on their needs. I do Modified Rolldown/Roll back, using the bolsters in a “T” position to prop them up. You can stand on the outside of the Cadillac for Arm Exercises such as Boxing.

WUNDA CHAIR: Leg Pumps on the Chair are fine but depending on how far along they are, their range of motion can be very limited. I’m more likely to use the Reformer for Footwork. I don’t do Seated Tricep Press here because the shoulder position is awkward and there are other ways to work the triceps. Mermaid tends to feel good but Side Arm Twist can be too compressive on the belly. Most other classical Chair exercises aren’t ideal since they are prone or require heavy flexion of the spine.

WALL TOWER: I like using the Wall Tower since it allows you to use the stability ball with many of the arm exercises.

BALL EXERCISES: As stated before in my answer to Michael, the stability ball is great for toning the pelvic floor. You can start with just postero-lateral breathing while on the ball, add TVA contractions and pelvic floor engagement, add pelvic tilts, lateral hip swings, then hip circles, (all good to mobilize the lower back which can tend to be tight). The ball is an excellent place to do arm exercises with the theraband: bicep curls, lateral raises, rotator cuff strengtheners. With the ball against the wall you can do pushups or squats and other hip strengtheners.

There are plenty of exercises I haven’t listed, some because they aren’t appropriate but others because they just simply aren’t in my current arsenal of go-to exercises. And my exercise program changes depending on my clients needs, as should yours. If you are in doubt, check the guidelines. If the exercise in question follows the guidelines and you are still in doubt, ask your client for feedback or simply choose something else. Remember there are plenty of other options. Be prepared to stop if it isn’t working and have alternatives ready. If you get stumped you can always have them take a break for water while you quickly regroup.

Good luck to you all,
Amanda

February 4, 2010 | Unregistered CommenterAnne

Thank you for doing this forum! I am a Pilates teacher and 1st time mom w/ 8 week old daughter:) I am interested in your Pilates "prescription" for both prenatal and postpartum clients - especially c-section recovery, diastasis recti & urinary incontinence. I find that the "acceptable" or "safe" exercises vary depending on who gives the advice and the client's situation, of course. Looking forward to hearing your thoughts.

Hi Jill,

There are tons of exercises that can be great during pregnancy and postpartum. However, instructors need to be knowledgeable about the anatomy and physiology of pregnancy, the musculoskeletal changes, hormonal changes, changes in center of gravity, and precautions for working with this group. Working with any special population requires training and skill. This population in particular requires some extra training as the pregnant and postpartum body is quite different than a regular body. In my two-day workshop, I focus more on teaching instructors concepts rather than a list of exercises. My next course will be May 29-30 at Kinected Center in NYC. Most instructors feel very ready to work with this population after this course.

The exercise focus is actually very similar during pregnancy and postpartum. During pregnancy, the main focus will be on TVA and pelvic floor strengthening. TVA strengthening during pregnancy is important for many reasons including: helping to support the growing uterus, prevention of low back pain, preparation for pushing, and diastasis recto control. Pelvic floor strengthening is also extremely important as this muscle group has the role of supporting the growing uterus from below. Both muscle groups become significantly stretched during the course of pregnancy especially during a vaginal birth. Strengthening these muscles during pregnancy will aide in the speed of the postpartum recovery process. My “prescription” is to design a program that has a heavy emphasis on TVA and pelvic floor stability as well as addressing the major postural changes brought on by pregnancy. Women should be taught how to close the diastasis by “drawing in,” and they should not perform any exercise in which they cannot keep the diastasis closed. Aggressive rectus abdominus strengthening should be avoided during pregnancy and early postpartum since the rectus has lost its integrity once the diastasis begins to open. Pilates practitioners should learn how to palpate the diastasis in order to make sure clients are able to keep it closed during exercise. Postpartum, women need to continue to focus on core stability with an emphasis on diastasis closure, rib cage closure, and pelvic balance.

C-section recovery is not much different than regular postpartum recovery except that there must be some attention paid to scar tissue mobilization. Women can begin to mobilize the scar as soon as it is healed which is generally by six weeks postpartum. Scar tissue mobilization is extremely important for prevention of adhesions. C-section scars are usually very thick and can create significant biomechanical issues if they are not addressed early on. Ways to mobilize the scar are to pinch it, lift it, and massage it. However, never apply pressure in a direction to pull it apart. Ultimately, we want the scar to behave like regular tissue.

It is common for women to have some mild stress incontinence during pregnancy due to the extreme pressure on the bladder, and it is also common for some women to have some stress incontinence issues initially postpartum. However, these symptoms should resolve by 12 weeks postpartum. In order to treat this problem, women may need to have manual therapy to balance the pelvis and pelvic floor following pregnancy and birth. Sometimes the pelvic floor can actually go into a rebound spasm after the extreme stretch during birth. Sometimes women are left very imbalanced in the pelvic floor after all the changes and pressure of pregnancy. Manual therapy can be necessary to help restore balance to the system. The manual therapy would have to be done by someone skilled in treatment of the pelvic floor. Then kegels, core stabilization, and hip stabilization will help to strengthen the system.

See my Safe Abs and Postpartum Recovery articles for more insight.

Thanks!
Debbi

February 4, 2010 | Unregistered CommenterJill

I have pulled away from Pilates during the past couple years because I've been struggling with getting pregnant (had one miscarriage at 7 weeks) and had read in a couple places that Pilates should be avoided by women struggling with infertility. I have a chance to finish my certification and would love to, I miss it! I would like to know the ins and outs of pilates for women dealing with "in"fertility and just for me how to go about the next month training and getting pilates back into my body without hurting my chances of getting pregnant. I'm 42 so I can't really postpone trying.
Ideally I'd like to have a good idea of what to do with clients (and myself) in the various stages of pre, pregnancy and post. Some of which you have answered above.
Thank you very much!

Hi Theresa,

I am by no means an expert on fertility but to my knowledge, I have never heard of any scientific research that indicates that exercise of any kind has an impact on fertility. I know that many women are instructed to “take it easy” while trying to conceive. However, I do not know if there is a real scientific basis to that recommendation. In fact, I would think that an exercise program like Pilates that incorporates breathing, stretching, and balancing of the body would actually be a positive step towards fertility. Pilates can help to increase energy and circulation through the pelvis which in my mind can only be a great thing. Pilates can also be a great way relieve stress which is a wonderful benefit while going through the fertility process. Fertility issues are very complex, and I think you should focus on doing things that make you feel happy and make your body feel good. Moderate intensity exercise should not impact fertility.

Again regarding how to generally work with pregnancy and postpartum clients, I'll just reiterate from previous posts that it is very difficult to answer such a general question. Working with this population, just like any special population requires special training. There are tons of exercises that can be great during pregnancy and postpartum. However, instructors need to be knowledgeable about the anatomy and physiology of pregnancy, the musculoskeletal changes, hormonal changes, changes in center of gravity, and precautions for working with this group. Working with any special population requires training and skill. This population in particular requires some extra training as the pregnant and postpartum body is quite different than a regular body. In my two-day workshop, I focus more on teaching instructors concepts rather than a list of exercises. My next course will be May 29-30 at Kinected Center in NYC. Most instructors feel very ready to work with this population after this course. Please also see my articles: Pilates and Pregnancy: Safe Abs and Postpartum Recovery for a general overview of working with this population, as well as the previous posts for more tips.

Best of luck,
Debbi

(Editor's note: Check out our May workshops page for more info on Debbi's course. Thanks! -Lauren)

February 4, 2010 | Unregistered CommenterTheresa

I am a Pilates teacher, and I am pregnant with my third baby (30 weeks). I have had two C-sections. In my second pregnancy I did Pilates on the apparatus until my seventh month and felt very well until I had to stop because I started to have contractions. Despite this, my recovery was excellent.In this pregnancy I haven't worked out because I'm often tired and nauseous (and now I have a two-year-old baby to take care of, too). I have lower back pain on my left side and the doctor told me that I have a small umbilical hernia.I miss my Pilates practice very much! Would you recommend that I start again at this time? I want to feel better!

Karla,

I think it would be great to start Pilates at this time as long as you take it slowly and adhere to the diastasis precautions, especially since you have been diagnosed with an umbilical hernia (i.e. no abdominal work in supine, no lifting the head and shoulders, no lifting double legs in the air, no plank pose...see my Pilates and Pregnancy: Safe Ab Exercises article). You should be focusing on lots of transversus abdominus strengthening, with an effort to approximate the rectus abdominus and close the diastasis. You can also work on upper and lower body strengthening, spine mobility, breathing and stretching.

Exercise can only be helpful for you. You will feel better, decrease stress, increase strength, increase flexibility, and improve respiratory function. Focused core stability work will help support the pregnancy and make the postpartum rehabilitation easier. It is NEVER too late to start exercising during pregnancy, but your workout may need to modified. After the birth, you will need to focus on abdominal rehab, being very careful to protect the hernia and not stress it. Wearing an abdominal binder or splint for the first few months can be very helpful. The pressure from the brace helps to physically approximate the abdominal muscles and can help them to heal more easily. It also provides a constant reminder to keep the transversus abdominus pulled in. I recommend the Tauts by Brooke Burke or a lighter weight splint by Julie Tupler.

Good luck!
Debbi

February 5, 2010 | Unregistered CommenterKarla

I'm currently teaching prenatal clients too. What are safe Pilates exercises that one can do on the ball????
please let me know
thanks in advance

Hi Lubna,

Amanda has answered your question up above, along with Anne's and AL's about the apparatus. Thanks for writing and make sure to take a look!

Best,
Lauren/Editor

February 8, 2010 | Unregistered Commenterlubna

Hi,

I have a new Pilates client who is 3 months pregnant and suffers from chronic back problems. She has a ripped disc between L5 and S1--an injury related to the wear and tear of being a former ice skater and basketball player. She is generally in very good shape, but she complains of back pain and low back "tightness." She is afraid her back pain will increase with the pregnancy. She would like me to build her a program that she can do at home, and she will see me for private, equipment-based studio sessions twice a month. Any suggestions about helping her have a relatively painless pregnancy? I have seen her once and she has extremely good body awareness and strong core support--she can access her core muscles and can stabilize her pelvis in supine fundamental mat exercises. Your input is appreciated.

Hi Simone,

That is fantastic that this client already has good connection to her core muscles and can stabilize her pelvis. That makes your job much easier. Regarding the herniated disc issue, generally the rule is to avoid flexion movements as this puts extra pressure on the vulnerable disc. In my experience, I have observed that often times old disc patients actually do very well during pregnancy. I believe that some of the reason they feel good is due to the hyperlordosis that happens as a result of pregnancy. The extra curve in the spine actually protects the herniated disc, and I have seen many women who were really worried about a disc problem have no issues. It seems that other back pain issues like general lumbar pain, sciatica, and SI joint pain are much more common.

So, with that said, your goal with this client is to teach her a comprehensive stability program focusing on neutral spine stabilization. We know that transversus abdominus strengthening helps to facilitate multifidus muscle contraction, and this helps with segmental spinal stabilization. I would design a program focusing on neutral spine transversus abdominus strengthening in sitting, supine, standing and quadraped as well as kegels. Instruct her in stretching for the piriformis, hip flexors, hamstrings, pectorals, and lower back. Shoulder bridge is also a great exercise for disc patients. She can be doing this on the mat, squeezing a ball, alternating leg lifting, or on a physioball. This client should also be working on upper back strengthening to help prevent excessive rounding of the shoulders as this posture puts more drag on the discs. Instruction in body mechanics for lifting would also be good information for this woman. Postpartum, she will be doing a lot of heavy lifting.

The real work for this patient will be during postpartum recovery. For any woman with a history of a herniated disc, the postpartum time is particularly vulnerable. After the birth, women have severely weakened abdominal and pelvic floor muscles. They have postural changes from pregnancy. They are exhausted, and they are doing a lot of sitting especially if they are nursing. Women need to be very careful not to strain their bodies during this time. Ideally, they should begin gentle TVA stability exercises immediately postpartum. They also need to try to pay attention to sitting posture and avoid slumping. Women can also begin walking as soon as they feel able but should refrain from jogging until they have recovered their full core stability. Women who begin gentle strengthening early on after the birth generally have a much easier recovery. Be sure to look at my Safe Abs and Postpartum Recovery articles for more tips.

Best,
Debbi

February 8, 2010 | Unregistered CommenterSimone

This question came in via email earlier this week, from Candace:

I have a client who had a C-section 15 years ago. What effect does that have on accessing core muscles? She has been seeing a PT who describes her as having facet syndrome in her lower back. What should be excluded and included?

Hi Candace,

The ability of your client to access her core muscles after a C-section 15 years ago depends on many things. Post C-section, women often have a more difficult time engaging their core muscles due to the pain and injury from the surgery. The C-section surgery does not actually cut the abdominal muscles, but does cut through the linea alba, the uterus, and connective tissue, which can cause the surrounding muscles to weaken. Since contracting the abdominals after the surgery is quite painful, many women will wait before starting an exercise program, which delays the rehab process and can make it harder when they do finally try to strengthen later on. In actuality, women should begin gentle abdominal strengthening like transverses abdominus (TVA) "drawing in" exercises the day after the surgery. This is the same idea as when people who have a knee or shoulder surgery begin gentle exercises immediately after. Orthopedic research indicates that the sooner we begin rehab after surgery, the better the outcome. Also, in orthopedics, we begin scar mobilization as soon as the scar is healed. This same logic should apply to post C-section rehab. Unfortunately, most women do not get any kind of rehab-based information following this type of surgery.

So, for a patient is who 15 years post C-section, if she is having trouble accessing her core, I would certainly check the scar for mobility. If you pull both ends of the scar out to the sides, if the scar puckers inwards, this indicates scar tissue adhesion. You should be able to lift the skin of a scar. If it is stuck down, that also indicates adhesion. If there are adhesions, then the scar must be mobilized. Scar mobility work is beyond the scope of a Pilates practitioner, so you may need to refer to a physical therapist. Just because a woman has a C-section, however, does NOT mean that she will have more problems strengthening later compared to someone who had a vaginal birth. Initially, it may be more difficult but later on, she will catch up. By 15 years postpartum, she should not have any lasting issues with core stability related to the C-section.

Facet syndrome is characterized by pain with compression of the facets. This occurs during spinal extension (back bending). If the lumbar spine is too compressed, the facet joints may become irritated. People with this issue tend to be hyperlordotic (sway backed). They generally have extremely tight hip flexors. Their psoas muscles are usually very dense. Someone in this posture will have a harder time accessing their core since they are unable to achieve a true neutral spine alignment. This client needs to work on lengthening her hip flexors and lumbar muscles to decompress the spine and take pressure off the facet joints. I would work on teaching her about
neutral spine position and stabilizing there, and then begin to gently progress her abdominal work being careful that she is not gripping her hip flexors. Shoulder bridge is a great position to strengthen the gluteals and hamstrings to open the hip flexors. Exercises like Spine Stretch forward and Saw are also good ones to help open up her back. I would stay away from any extreme extension exercises like Swan Dive, but beginning level Swan would actually be good. Teaching her how to extend while stabilizing with the abs to protect her low back would probably help her very much. Pilates done slowly and carefully should be an excellent tool for this client.

Best,
Debbi

February 10, 2010 | Unregistered CommenterDebra Goodman

Hi again,

I have a private client who is 11 weeks pregnant and has a herniated disk on L4 and L5. What exercises are contraindicated for her? I was thinking of focusing on pelvic tilts and sit ups but i dont want to aggravate her injury. She is on a course of pain killers but has been relatively pain free. She hasn't done Pilates before. What would you suggest?

Many thanks.

Hey Lubna,

At this early stage in her pregnancy I think your focus should be on her L4-L5 herniation. Herniations at the lumbar spine often protrude posteriorly and laterally and can be a result of an already flattened lumbar curve. With this decreased lordosis, flexion may actually exacerbate her symptoms so I would NOT focus on posterior pelvic tilts and sit-ups. This population needs stability before mobility. Work in a neutral pelvis position (or work toward neutral, if she's not there yet) and focus on exercises that highlight core stability and hip differentiation (i.e. making sure the leg moves independently from the pelvis). Abdominal curls with a neutral pelvis can be challenging to someone new to Pilates, so find other exercises and positions that challenge her abdominals - knee folds, leg slides, quadruped position work. Multifidi training and other exercises to stabilize the spine, like plank, would also be beneficial. It is also important to stretch and strengthen the piriformis and to stretch the psoas. Avoid exercises that compress the lumbar spine like Roll Up and be careful with exercises that round the back.

Encourage your client to listen to her body and give you feedback. I would also be careful about pushing her range of motion. The combination of relaxin hormone and pain medication may give her a false sense of a pain-free range of motion. As you continue to work together follow the guidelines for pregnancy as well as the modifications for disc herniations.

Good luck,
Amanda

February 11, 2010 | Unregistered Commenterlubna

I recently heard that pregnant women should avoid asymmetrical work (particularly in the hips) b/c of the pelvic instability. Have you heard of this and if so, could you tell me more.... Thanks!

Hi Sarah,

I am not exactly sure what you mean by asymmetrical work, but I can say that during pregnancy and early postpartum, I do not include side-lying leg work. I have found over the years that side-lying leg work can put too much strain on the vulnerable sacroiliac joints.

During pregnancy, the relaxin and estrogen hormones cause the body's joints, ligaments, and connective tissue to become extremely lax. The whole body is affected by this, but this laxity is particularly noticeable in the joints of the pelvis. The SI joints and pubic symphysis can become extremely hypermobile, and often this hypermobility is not symmetrical--one SI joint may be more mobile than the other. Therefore, it becomes increasingly difficult to stabilize the pelvis when this hypermobility is combined with the changes of the musculoskeletal system. Sidelying leg work, especially long lever work like side leg raises or pulling leg springs, may put too much force through the vulnerable SI joints which can irritate them or cause the pelvis to get pulled out of alignment.

Since I have witnessed several clients feel pain after doing sidelying leg work, I have now completely taken those movements out of my prenatal program. I only do lower extremity exercises that use both legs or work the legs in the sagittal plane (front to back). Movement in the sagittal plane does not seem to have the same negative effect and actually helps to strengthen and lengthen the psoas and strengthen the gluteus maximus. Examples of safe exercises that will not stress the SI joints are: bridging (on mat, ball, reformer, bilateral, and advanced unilateral); supine ball squeezing for adductors, foot work on the Reformer, supine straight leg raises (parallel and turned out), quadraped swimming, and standing single leg balance work.

Best,
Debbi

February 11, 2010 | Unregistered CommenterSarah

I have a client, about 30, in good physical shape. She has done Pilates before, but several years ago. She had a miscarriage about 8 months ago and is now trying to get pregnant again. She wants to start up with Pilates again now. Do you have any reason that she should not start up?

Hi Tasha,

There is no reason that this client should not start Pilates at this time. Miscarriages occur because there is something wrong with the embryo, NOT from exercise. Exercise can NOT induce a miscarriage. An exercise program like Pilates that incorporates breathing, stretching, and balancing of the body is tremendously beneficial for women in body and mind. Pilates will also help her strengthen her body as she prepares for pregnancy, and if she is working with a skilled instructor knowledgeable about the needs of pregnant women, she will continue to support her body as her pregnancy progresses. It will be lots of fun for you to work with this client and support her all the way through her pregnancy and birth.

Best,
Debbi


February 15, 2010 | Unregistered Commentertasha

Hello,
I have a client that has just started Pilates reformer class with me. She is about to go through IVF. Assuming that the pregnancy takes and her doctors are OK with her continuing to work out, is there anything different to be aware of in a pregnancy like this, as opposed to one that was concieved normally?

Hi Joanna,

Once the pregnancy is established, it does not matter how it was conceived. In fact, once an IVF conception is confirmed and is progressing well, most women will switch to a regular OB. So no, there are no special or different precautions for an IVF-conceived pregnancy. Just make sure your client is working out safely!

Best,
Debbi

February 19, 2010 | Unregistered CommenterJoanna

This question came in via e-mail, from Emily Power:

Hey Ladies!

Hope all is well... Any recs for separated pubis symphasis? My client wears the belt her PT gave her, but it annoys her in class.

Thanks!!

Hi Emily,
This is a great question because there is a lot of confusion about pubic bone issues. The term "Pubic Bone Separation" actually refers to an extremely severe condition when the pubic bone literally separates. This generally happens as a result of giving birth, when the pubic symphysis is strained and tears due to extreme pressure. There is usually warning before this happens. Leading up to the birth, women will be in EXTREME pain with inability to walk well or shift weight to one leg.

However, this term is loosely used in the OB community when they are referring to any kind of pubic bone pain. The majority of pubic bone pain is the result of a misaligned pelvis. Due to the extreme hypermobility of pregnancy, the pelvis becomes far more likely to rotate out of alignment. The cause of the rotation is generally due to one hip being tighter than the other. If the gluteals and external rotators are much tighter on one side of the pelvis, this can pull the pelvic bones and sacrum out of their proper alignment and cause pain in the buttocks, SI joint, or pubic bone regions. In my experience, once the pubic bone is involved, the tightness has become severe. Often these women will also have or have had buttock or SI joint pain first.

To treat this problem, manual therapy is extremely necessary. Deep tissue massage is essential to release the gluteals and external rotators, and this massage is often quite uncomfortable. Then the pelvic alignment must be restored through manual therapy. Afterwards, these women need to use a tennis ball to continue to work on their glutes and rotators at home, and do piriformis stretching 2-3 times daily. They need to also do abdominal/pelvic-stabilization exercises to support the pregnancy, to help hold the pelvis in a more balanced position, and to control the diastasis recti. A big diastasis recti can also cause more protrusion of the belly which puts more pressure on the pubic bone. Once the cause of the pelvic rotation has been identified and released, women should be able to continue to manage their symptoms with exercise independently. Severe pubic bone pain can take several sessions before the problem is controlled. I only recommend the belt if there is extreme hypermobility, and binding is necessary. Most women do not like the belt as it does shift during movement. It sounds like this woman’s pain is not extreme though if she is in your exercise class. Once alignment is restored and her pain has decreased, you can continue an appropriate prenatal exercise program, being very conservative with your lower extremity strengthening choices. Stay away from any side-lying leg raises as this puts too much force through the unstable pelvis and stretch, stretch, stretch those hip muscles!

Best of luck,
Debbi

February 24, 2010 | Unregistered CommenterLauren Charlip/Editor

I am an instructor who has been under the care of a fertility specialist and have under gone 2 IUIs and 3 IVFs in the past year. I have never been advised to stop practicing Pilates. Actually, I have been encouraged. I have many clients who are going through the samething and Pilates has been their escape from the madness of infertility.

February 24, 2010 | Unregistered CommenterAmy

Huge thanks to Debra and Amanda for taking the time to be "on call" throughout the month of February. We've learned a lot from them and hope you have, too. Don't miss Debra's Exercise Through Pregnancy workshop, if you're able to make it to the New York City area on May 29-30. And if you're interested in hosting one of her workshops, don't hesitate to drop her a line here.

Thanks to everyone for participating. If you have suggestions for future Pilates On Call hosts, please send an e-mail to editor@pilates-pro.com.

March 2, 2010 | Registered CommenterLauren Charlip
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