Pilates and pregnancy

Adi Balogh
is director of the
Swiss Cottage Pilates
Studio, London
220 Midwives The official journal of the Royal College of Midwives Vol 8 N
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5 May 2005
Wellbeing
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 princi-
ples 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 under-
stand 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 users 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
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.
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.
Box 1. Biomechanical changes of pregnancy
Centre of gravity moves forward
Muscles tighten and shorten:
I Pectorals
I Iliopsoas
I Hamstrings
I Lumbar extensors.
Muscles lengthen and weaken:
I Rectus abdominus
I Gluteals.
Posture changes:
I Increased lumbar lordosis
I Increased thoracic kyphosis.
Pressure on pelvic floor muscles increases
Rib cage flares upwards
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Wellbeing
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 one-
to-one tuition in the first instance.
Pelvic floor
Pelvic floor muscles
play an important
part in our pelvic-
spinal 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 through-
out 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 trans-
verses 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
OToole, 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
A mother and her baby taking part in a Pilates class
Women concentrate on an equipment-based Pilates exercise
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222 Midwives The official journal of the Royal College of Midwives Vol 8 N
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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 strength-
ening the core stabilising muscles around the
pelvis and spine, and improving the breath-
ing 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 move-
ments are introduced to challenge this core
stability. This philosophy is clearly applicable
in pregnancy a significant test both mental-
ly and physically on the mothers body.
By maximising the mothers 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 mothers physical and
mental wellbeing she looks after her babys
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, OToole 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 preg-
nancy. Obstetrics and Gynecology 71(1): 71-5.
Boissonnault JS, Blaschak MJ. (1988) Incidence
of diastasis recti abdominis during the child-
bearing 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.
Wellbeing
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