BSPT2020 SEM1 CASE10: POST PREGNANCY CONDITION

February 12, 2019 (TUE - 1:00 - 5:00 PM)

REPORTER’STASK/S: (1) Complete the Initial evaluation given by providing the appropriate
interpretation and significance in the PE findings, creating complete PT impression and Prognosis,
setting realistic Goals and formulating a comprehensive Treatment Plan; (2) Answer ALL given guide
questions and make suitable patient education materials; (3) Present the case in the SEM1 class

INITIAL EVALUATION General

Data:
Name: U.I.
Age: 40 years old
Religion: Catholic
Gender: Female
Address: Malakas St., Quezon City Contact
Information:
Religion: Catholic
Date of Consultation: Dr. V.S. Date
of Referral: July 16, 2017
Physiatrist: Dr. S.V.
Type of Patient: Out-patient
Date of IE: September 2, 2017
Informant/ Reliability: Patient / Good
Dx: LBP with urinary incontinence & diastasis recti (3 fingerwidths) Chief
Complaint: low back pain (6/10 ps)

Premorbid status: Patient is apparently normal in all aspect of ADL.

HPI:
One month PTIE: Patient reported that her condition started in the last trimester of her
pregnancy which is worse from static posturing as the day progress. Relief of pain when she
change in position or start to do some walking activities. It is characterized as dull
intermittent pain on both low back area with pain scale of 6/10. She has not consulted an
doctor until now.
Patient reported that experienced urinary leakage which occurs with forceful
coughing and sneezing. She is now wearing minipads on a daily basis. The patient has also
noticed a worsening in her incontinence symptoms and denies urinary urgency unless she
has a very full bladder. She voids every three to four hours and experiences nocturia one
time nightly. Reports that she is very anxious about participating in physical therapy.
Patient is independent in all aspects of ADL.
At present: Reports that she is very anxious about participating in physical therapy and
patient is independent in all aspects of ADL.

Past Medical History

(+) urinary incontinent since delivery of eldest child; occurs with forceful coughing and
sneezing, however, in the past year, she noticed an exacerbation of the leakage)
(+) depression (Dx: 3 years ago)
(+) prediabetic level (diagnosed a year ago; advised to control diet and engage in exercise)
(+) hospitalization due to childbirth; has 2 children with youngest delivered 3 months ago,
all vaginal delivery)
(+) recurrent urinary infection
(-) allergies
(-) pelvic condition
(-) cancer
Ancillary Procedure:
Urinalysis (July, 2017, no infection)

Medications:
Medication Dosage/Frequency Indication Side Effect
Stress tab od
Metformin 500 mg/ od
Alaxan prn

Personal/ Social/ Occupational/ Environmental Hx:

• She ingests four to five cups of caffeine per day
• smokes when stressed (average 2 sticks/ week / 2 years ago)
• single mother with 2 children (ages 3 and 3 months old)
• not financial and emotionally stable since husband left her 2 years ago
• PT Goal: to be able to get better and not feel embarrassed with her condition
• Works at her own weaving business
• Usual diet consistent of meat and very few vegetables
• Occasional beer drinker
• Had not participated in any recreational or sport activities
• Has one stay-in househelp
• Lives in bungalow style house, bathroom is 20 meters away from the bed

PHYSICAL EXAMINATION General Survey

• Alert, coherent, cooperative
• Ambulatory without assistance & assistive device
• Endomorph (193 lbs, 5’0 ft)
• Not in apparent pain and respiratory distress
• (-) postural and gait deviation

Vital signs
Before During After
BP (mmHg) 110/70 110/80 110/80
PR (bpm) 80 82 82
RR (cpm) 16 17 18
Temperature Afebrile to touch Afebrile to touch Afebrile to touch
Int: Patients vital signs are within normal limits
Sig: Results will be use as a precaution during exercise and the use of modifications

SKIN
• Normothermic on all exposed body parts
• (-) Trophic skin changes on (L) UE
• (-) Skin lesion

HEENT
• Not assessed

Heart
• (N) HR and rhythm
• (N) heart sound

Chest and Lungs

• (N) breathing pattern (thoracic breather)
• (-) swelling on the chest
• (-) erythema on the chest
• (-) chest deformity
• (-) chest asymmetry

Back and Spine

• (+) muscle spasm at low back area bilateral
• (+) tenderness on the back
• (-) erythema on the back
• (-) spine deformities

Abdominal Examination:
• (+) Abdominal protuberance
• (+) diastasis recti (3 fingerwidths) below and above the umbilicus

Extremities
• (+) hallux valgus at the right big toe
• (-) erythema on (B) UE and LE
• (-) discoloration on (B) UE and (B) LE

ROM: All motions of the both UE/LE are WNL and actively done and painfree.
Int: The patient has intact joint mobility
Sig: The patient can perform exercises provided by PT intervention without difficulty

MMT: All muscle groups of both UE/ LE are grossly graded as 5/5 except for trunk flexion
and lateral flexion both graded as 2/5.
Int: Patient presents with weak trunk flexors and lateral flexors which may be a result of
muscle imbalance
Sig: Treatment procedures should include exercises to strengthen abdominal muscles

Sensation: Intact sensation on all body parts as pain, light touch and deep pressure.
Int: The patient has intact sensory integrity
Sig: Patient can modalities for intervention
Postural Assessment: essentially normal except for protruding abdomen and increase
lumbar lordosis in lateral view
Int: Patient presents with sway back deformity due to weak abdominals secondary to
post pregnancy.
Sig: Patient experiences low back pain that may affect her basic ADL as to self care and
mobility .

Gait Analysis:
Int: Patient has normal gait pattern
Sig: Patient does not have difficulty in walking

ADL: Patient is independent in all aspects of ADL.

GUIDE QUESTIONS:
1. What is your PT diagnosis/PT Impression based on APTA’s Preferred Practice
Pattern, ICD 10 Classification and ICF. Explain your PT diagnosis/PT impression based
on the phase/stage/severity of the condition patient is in as well as the anatomical
structure/s responsible for the patient's clinical manifestations.

Patient is having difficulty in performing her role as a worker in a weaving business and
being a mother d/t unexpected leakage during forceful coughing and sneezing brought
about by urinary incontinence; low back pain which due to impaired muscle
performance as manifested by diastasis recti and weakness of trunk flexors/lateral
flexors and impaired posture as manifested by increased lumbar lordosis and protruding
abdomen which are all secondary to post induced pregnancy guided by the APTA
pattern 4B and 4C.

Patient also experiences nocturia nightly and worsening of low back pain during static
posturing.

Risk Factors or Impairments of Body Patient

Consequences of Functions and Manifestations
Pathology/Pathophysiolo Structures, Activity
gy (Disease, Disorder, or Limitations, or
Condition) Participation Restrictions

Pattern • Congenital • Impaired joint • Weak

4B: torticollis mobility lateral
Impaired • Pain • Inability to trunk
Posture • Pregnancy tolerate prolonged flexion and
• Repetitive sitting trunk
stress syndrome • Leg length flexion 2/5
• Scheuermann discrepancy • Low
disease • Muscle back pain
• Scoliosis, imbalance NRS 6/10
kyphoscoliosis • Muscle •
weakness Urinary
Leakage
during
forceful
coughing
and
sneezing
•
Nocturia
nightly
•
Voiding
every 3 to
4 hours
 Pattern • Acquired • Decreased • Low
4C: immune deficiency functional work back pain
Impaired syndrome capacity NRS 6/10
Muscle • Chronic • Decreased •
Performan musculoskeletal nerve conduction Urinary
ce dysfunction • Diastasis recti Leakage
• Chronic • Inability to climb during
neuromuscular stairs forceful
dysfunction • Inability to coughing
• Diabetes perform repetitive and
• Down syndrome work tasks sneezing
• Pelvic floor • Loss of muscle •
dysfunction strength, power, Nocturia
• Renal disease endurance nightly

• Vascular • Stress urinary •

insufficiency incontinence Voiding
every 3 to
4 hours
• Weak
lateral
trunk
flexion and
trunk
flexion 2/5

ICD 10 ICD-10-CODE N39.46 (Mixed

CLASSIFICATION incontinence)
ICD-10-CODE M62.0 (Diastasis Recti)
ICD-10-CODE N39.4 (Low back pain in
pregnancy)
 Structur Reasons
es in
order of
priority
1 MUSCL According to Kisner abdominal and pelvic floor muscles become
E: stretched to the point of their elastic limit which greatly decreases
• the muscles ability to generate forceful contractions; In this case
Abdo the patient present diastasis recti, complains of LBP and leakage.
minal Diastasis recti may produce musculoskeletal complaints, such as
musc low back pain, possibly as a result of decreased ability of the
les abdominal musculature and thoracolumbar fascia to stabilize the
• pelvis and lumbar spine on the other hand pelvic floor muscle
Pelvi helps in maintaining continence in the urethra.
c
floor
musc
les

2. Discuss the subjective and objective findings that would support your PT
Diagnosis/PT Impression. How are your subjective and objective findings inconsistent
with your differential diagnosis (PT diagnosis)? Discuss the pathophysiology/patho-
mechanisms involved by presenting the disease illness and patient illness script for the
given case. Also consider other medical conditions related to the patient’s clinical
presentation, if applicable. Present the medication reconciliation with its PT implication/s
based on the given drug history.

Subjective Findings Objective Findings

● Female ● Ambulatory without

● 40 years old assistance & assistive
● Pt’s complains of low back pain (6/10 ps) device
● Pt reported that she is very anxious about ● Endomorph (193 lbs,
participating in physical therapy and patient 5’0 ft)
is independent in all aspects of ADL. ● (+) muscle spasm at
● Pt had (+) urinary incontinence, (+) low back area bilateral
 depression (diagnosed 3 years ago), (+) pre ● (+) tenderness on the
diabetic level, (+) hospitalization d/t child back
birth and (+) recurrent urinary infection ● (+) Abdominal
● smokes when stressed (average 2 sticks/ protuberance
week / 2 years ago) ● (+) diastasis recti (3
● Pt is taking medication fingerwidths) below
● PT Goal: to be able to get better and not feel and above the
embarrassed with her condition umbilicus
● (+) hallux valgus at
the right big toe
● Weakness of trunk
flexion and lateral
flexion
● Increased lumbar
lordosis

Componen Disease Illness Script Patient’s Illness script

ts

Mechanis Postpartum period is defined as 6 Based on the HPI of the

m weeks after child birth. At this period
the body and reproductive tract will
slowly return to normal however,
abnormal physiologic changes may
not return to non pregnant stage up
to 12 months or other will not at all.
Condition such as stress urinary
incontinence,incontinence of flatus or
feces, uterine prolapse, cystocele,
patient, she experienced
urinary leakage during
forceful coughing and
sneezing. She voids every
three to four hours and had
once experienced nocturia.
There was a history of urinary
inconsistency since the
delivery of eldest child and
and rectocele happens at this stage.. has recurrent urinary
infection.

Urinary Incontince

According to Cunninghan (2015),

there is a uterine changes after
spontaneous vaginal delivery,
primarily urinary tract changes.

Urine Incontinence is defined as

involuntary leakage of urine.
(Hoffman, 2012)

There are two types of incontinence

in pregnant women. First, the stress
urinary incontinence-- it happens
during exertion and or sneezing or
coughing in which there is a
involuntary leakage of urine. Second,
urge urinary incontinence where in
there is a perceived forceful imminent
need to void.

Diastasis Recti

Diastasis recti is defined as

separation of abdominis muscle in
the midline of the linea alba. Any
 separation greater than 2
fingerbreadths above, below or at
the level of umbilicus is considered to
be abnormal.

Postural Related Back pain

Postural related back pain- It is

considered as postural changes
during pregnancy and may last up to
childbirth. This is due to increased
ligamentous laxity, hormonal
influences, and decreased
abdominal muscle function

Epidemiolo Urinary Incontince ● Patient is women

gy ● Patient is 40 years old
One out of four women will seek ● Patient is obese (37.7
advice for incontinence due to kg/m2).
embarrassment, limited access to ● Patient is ambulatory
health care or poor screening by without assistance &
health care providers assistive device\
(Hagstad,1985). ● Had delivered 3 child
all were vaginal
Stress urinary incontinence is the delivery
most common for ambulatory ● Smoke when stressed
women. ● Patient experienced
urinary leakage during
Risk factors: forceful coughing and
sneezing.
Age ● Postpartum (3 months)

80 years above due to several

physiologic changes occur in the
lower tract such as involuntary
detrusor contraction, decreased
bladder capacity and ability to
postpone voiding, decreased
estrogen level which resulted to
atrophy of urethral mucosal seal, loss
of compliance, bladder irritation and
alterations in diurnal levels of
antidiuretic hormone and atrial
natriuretic factors which changes the
pattern of fluid excretion toward one
greater in urine excretion in the day.

Obesity: those who have increased

body mass index will result in a
higher intravesical pressure.
Child birth and pregnancy: It could
result from direct injury to pelvic
muscles and tissue attachments
thereby causing pelvic muscle
dysfunction. Also a child birth > 4000
g.
Vaginal delivery > Ceasarian delivery

Family history: Daughters of

incontinent women had an increased
relative risk of 1.3 and absolute risk
of 23 percent of having urinary
incontinence (Hannestad, 2004)

Smoking and chronic lung disease:

Cigarettes smoker > Non smoker
Those who are previous smoker and
currently smoking with an average of
20 cigarettes daily.
Other risk factors:

Hysterectomy
Menopause

Diastasis Recti

Bouissanault and Blaschak

conducted a study in diastasis recti. It
 has been reported that the incidence
of diastasis recti is 0% in non
pregnant women, 27 % in second
trimester and 66% in third trimester
and 36 % of postpartum women
between 5 weeks and 3 months
continued to display a separation.

Postural related low Back pain

50 % of the pregnant women

population reported back pain and it
continues up to 12 months after
delivery where in there is
approximately 68 % of them.

Duration Stages of disease progression: The patient is currently in the

The initial or acute priod- (6–12 hours third phase or delayed
postpartum). This is a time of rapid postpartum since it is almost
change with a potential for immediate 3 months when they patient
crises such as postpartum had give birth and yet the
hemorrhage, uterine inversion, patient has urinary
amniotic fluid embolism, and incontince, lower back pain
eclampsia. and diastasis recti.
 The second phase or subacute
postpartum period- (2–6 weeks).
changes in terms of hemodynamics,
genitourinary recovery, metabolism,
and emotional status occur.
This is less rapid where in the patient
is generally capable of self-identifying
problems. Ordinary concerns about
perineal discomfort to peripartum
cardiomyopathy or severe
postpartum depression arise.

The third phase or delayed

postpartum period- which can( last up
to 6 months). Changes during this
phase are extremely gradual, and
pathology is rare. This is the time of
restoration of muscle tone and
connective tissue to the prepregnant
state.

Clinical Signs and symptoms ● Patient reported that

Presentati experienced urinary
on Urinary Incontinence during: leakage which occurs
● Cough with forceful coughing
● Sneeze and sneezing.
● Laugh ● experienced nocturia
● Stand up once nightly
● Get out of a car
● Lift something heavy
 ● Exercise
● Have sex
● Greater than 20 voids per day
● Nocturia

Diastasis Recti

Classification of diastasis recti:

Normal: Any separation above, below

or level of the umbilicus of <2.5 cm
without bulging

Mild: Separation above, below or

level of the umbilicus of >2.5 cm with
<3.5 bulging

Moderate: Separation above, below

or level of the umbilicus of >2.5 cm The patient has 3
with <3.5 bulging <2.5 fingerbreadths above and
below the umbilicus
Severe: Any separation >5.0

Low Back Pain

Symptoms:

It usually worsens with muscle

fatigue from static postures or as the
day progress. It can be relieved by
rest or change in position
Patient reported that her
condition started in the last
trimester of her
pregnancy which is worse
from static posturing as the
day progress. Relief of pain
when she
change in position or start to
do some walking activities.
Diagnosis LBP with urinary Incontinence APTA Pattern 4C Impaired
Diastasis Recti muscle performance and
APTA Pattern 4B Impaired
Posture

Medicatio Dosage and Indication Side effect

n frequency

Stress tab od Vitamin deficiency Constipation, diarrhea, upset

prevention due to stomach
poor diet, certain
illness or during
pregnancy

Metformin 500 mg/ od Type II diabetes or Nausea, vomiting, stomach

high blood sugar upset, diarrhea, weakness, or a
metallic taste in the mouth may
occur.

Gastrointestinal disturbances;
lactic acidosis may also occur in
rare cases and this effect may
be severe or fatal

Alaxan prn/325 mg of Relief of pain Diarrhea, dizziness excess

Paracetamol associated with fluids build up inside the body
with 200 mg headache, (fluid retention), headache,
of Ibuprofen backache, heartburn, increased alanine
migraine, period aminotransferase, increased
pain, muscular blood creatinine, increased
pain, dental pain, blood urea, increased gamma
sore throat, cold glutamyl transferase, indigestion
and flu symptoms, (dyspepsia), loss of appetite,
and fever. nausea, nervousness, rash
ringing in the ears, severe skin
 Reduce itching, stomach discomfort,
inflammation stomach, pain vomiting

3. How is the severity or nature of the condition going to affect your treatment? Are
there any treatment considerations / specifications / guidelines related to the current
phase of rehabilitation for this patient?

Based on the patient’s presentation, she is currently in the delayed postpartum

period specifically in the 3rd month after vaginal delivery where in the symptoms of a
pregnant woman still are still present; in the case, the patient still presents with are low
back pain and leakage which is normally occurring to pregnant women which may
continue to persists even after pregnancy according to Kisner. For the treatment of this
patient, according to Kisner it is important to decrease the separation of the muscle by 2
cm prior to engaging in strenuous activity or exercise while being cautious in the
patient’s depression, and voiding hours.

4. Are there any precautions or contraindications to PT interventions based on the

subjective and objective findings?

Precaution Contraindication

● Joint laxity might be present thereby, the ● Excessive bleeding

treatment must include warm up and cool ● Valsalva maneuver
down during exercise
● Diastasis recti ● Heavy lifting and
● Urinary incontinence sudden twisting of the
● Depression spine
● Drug intake and duration
● Had not participated in any recreational
activity or sports
 ● Ingesting 4 to 5 cups of caffeine per day
● Risk for fall
● Regulation of VS

5. After a careful evaluation of all the findings, decide on any further examination
(including other ancillary procedures) that is required by PT or that requires referral or
delegation to another professional to rule out or implicate coexisting conditions and
contributing factors.

PHYSICAL EXAMINATION

Pelvic organ prolapse evaluation

● Patients who have poor urethral support will commonly accompanies pelvic
organ prolapse. This is to assess the pelvic organ of the patient.
Bulbocavernosus reflex
● This is used to assess if there is any neurological presentation.
Q-tip test
● It used to assess the pelvic relaxation and mobility of urethra.

REFERRAL

Psychiatrist- To determine if the patient is currently suffering from depression since she
was diagnosed 3 years ago

Occupational Therapist- To manage the anxiety of the patient.

ANCILLARY PROCEDURES

Postvoid Residual (PVR)

 ● It is measured during incontinence evaluation which may rule out recurrent
infection, urethral obstruction from the pelvis mass, stress urinary incontinence
and other neurologic deficit
Postoperative postvoid residual
● This could be done if the patient underwent anti-incontinence surgery. It could be
a helpful indicator to completely empty her bladder
Simple cystometrics
● It is an objective measurements of bladder function which determine the stress
incontinence and detrusor activity, desire to void and bladder capacity.
Uroflowmetry
● It can identify the woman’s ability to empty her bladder and its urinary retention
and other types of voiding dysfunction
Cystometrography
● It aims to determine whether there is a urodynamic stress incontinence or
detrusor overactivity. It test allows information on a bladder threshold volumes at
which the woman senses bladder capacity
Pressure flowmetry
● It is a type of urodynamic testing that is helpful in determining bladder outlet
obstruction
Urethral Pressure profile
● It will measure the strength of the urethra during urethral pressure.

6. Identify / categorize the patient’s problems in terms of impairments of body

functions, functional limitations, activity restrictions/ disability and other contextual
factors using the ICF framework. Prioritize the identified existing and potential problems
in the case. Justify your prioritization.

LBP with urinary incontinence & diastasis recti (3 finger widths)

BODY ACTIVITY (TASKS) PARTICIPATION

STRUCTURES/FUNCTIO RESTRICTION
NS (IMPAIRMENTS)
 ● Dull Activities: Activities:
intermittent - - Works at
pain on both Independent her own
low back area in all aspect of weaving
with pain ADLS business
scale of 6/10 Limitations: Limitations:
● Weakness of - Void every - Mild
trunk flexion 3 to 4 hours difficulty in
and lateral performing
flexion role as a
● (+) muscle mother and a
spasm at low worker in a
back area weaving
bilateral business d/t
● (+) leakage upon
tenderness forceful
on the back coughing and
● (+) Abdominal sneezing.
protuberance
● (+) diastasis
recti (3 finger
widths
) below
and above
the umbilicus
● (+) hallux
valgus at the
right big toe
● Increased
lumbar
lordosis

CONTEXTUAL FACTORS

PERSONAL FACTORS ENVIRONMENTAL FACTORS

+ +
· (-) allergies · Works at her own weaving
· (-) pelvic condition business
· (-) cancer · Has one stay-in househelp
· Urinalysis (July, 2017, no · Lives in bungalow style house
infection)
· Ambulatory without
assistance & assistive device

- -
· (+) urinary incontinent since - Nature of work:
delivery of eldest child; occurs prolonged standing
with forceful coughing and - Bathroom is 20 meters
· sneezing, however, in the away from the bed
past year, she noticed an
exacerbation of the leakage)
· (+) depression (Dx: 3 years
ago)
· (+) prediabetic level
(diagnosed a year ago; advised
to control diet and engage in
exercise)
· (+) recurrent urinary
infection
· She ingests four to five cups
of caffeine per day
· smokes when stressed
(average 2 sticks/ week / 2
years ago)
· Usual diet consistent of meat
and very few vegetables
· Occasional beer drinker
 PROBLEM LIST Justification

1. Pelvic Floor weakness We will be addressing this problem first

because of the patient report of
worsening incontinence which may be a
factor of her being anxious in participating
physical therapy program.

2. Diastasis recti/Weakness of Diastasis recti will be the second because

trunk flexion and lateral it may produce musculoskeletal
flexion complaints, such as low back pain,
possibly as a result of decreased ability of
the abdominal musculature.

3. Postural deviation: Increased Postural deviation will be the last because

lumbar lordosis and protruding
abdomen and low back pain
according to the patient complaint it is
only worse during static posturing and me
only be due to habitual posturing because
of pregnancy which will not be elicited
during physical therapy session

7. Discuss your long-term and short-term goals. Considering your goals and
outcome for this patient, what would be the focus of your rehabilitation program and
why?

LTG
The patient will present decreased frequency in urination as manifested by increase
pelvic floor muscle strength s pain on the low back and decreased
The patient will be able to present no pain on the lower back as manifested by correct
posture and with decreased diastasis recti of 1 fingerbreadth after 3 months of PT
session.
 PROBLEM LIST SHORT TERM GOAL

1. Pelvic Floor weakness The patient will present increased

strength of pelvic floor muscles as
manifested by decrease number of
voids at least 6 times per day after
8 PT session

2. Diastasis recti/Weakness of The patient will present with

trunk flexion and lateral decreased diastasis recti from 3
flexion finger breadths to 2 finger breadths
after 8 PT sessions.

The patient will present with

increased muscle strength of trunk
flexion and lateral flexion from ⅖ to
⅗ after 18 PT sessions

3. Postural deviation: Increased

lumbar lordosis and protruding
abdomen and low back pain
The patient will demonstrate
proper posture c minimal verbal,
visual or tactile cueing all
throughout PT sessions.

The patient will report decreased

pain from 6/10 to 4/10 after 2 PT
sessions.

8. How will you manage this patient? Design your PT plan of care. Provide a brief
rationale (i.e. research evidence) that justifies your choice of intervention. Be sure to (a)
describe your treatment progression over time; (b) discuss how many treatments would
be required and (c) create a comprehensive ward instruction/home exercise program for
patient education using the most suitable education materials (pamphlets, brochure,
video presentation, etc.) appropriate (literacy level/ cognitive barriers) for your patient
including dietary recommendations if necessary.
PROBLEM LIST INTERVENTION JUSTIFICATION

Pelvic Floor Kegel exercises x 3- According to

weakness 5 SH x 10 reps x 3 Braddom, Kegel
sets exercises showed a
great capacity to
*This can be strengthen the
performed 30-40x a pelvic floor muscles,
day or as much as which support the
possible uterus, bladder,
small intestine and
*Biofeedback Therapy rectum. This
exercises benefit
women who is
Contract relax of the suffering from
pelvic floor x 5SH x urinary
10 reps x O.D incontinence.
According to
Quick contractions braddom,
of the pelvic floor x Biofeedback with or
10 reps x 2 sets x without electrical
O.D stimulation is often
used to improve the
Elevator exercise x ability to perfrom
10 reps x 2 sets x pelvic floor muscle
O.D contraction to
increase the support
Pelvic floor to the bladder and
relaxation x 10 reps urethra to maintain
x 2 sets x O.D urethral closure.

Diastasis Recti (3 According to kisner

finger breadths) / Head lift Exercise x (2013), the diastasis
weakness of trunk 10 reps x 2 sets x recti must be
flexion and lateral O.D checked before
flexion initiating abdominal
Head lift with Pelvic exercises. Exercises
tilt exercise x 10 must be limited into
reps x 2 sets x O.D head lift and head
lift with pelvic tilt
If the diastasis recti until the diastasis
is less than 2 cm recti becomes 2 cm
proceed to this or less
exercise

Drawing in
maneuver x 6SH x
10 reps x O.D

Basic stabilization
lumbar exercise x
10 reps x 2 sets x
O.D
● Bent leg lift to
90 deg.
● Heel slide to
extend knee
● Straight leg
lift

Basic Lumbar
stabilization with
progressive limb
loading x 10 reps x
2 sets x O.D

Progression

- Increased the
number of
repetition
- Use of
external
props
- Extreme
loading
- External
resistance
- Position
changes
- Unstable
surface

(All of this may vary

according to
patient’s response
 and muscle
performance)

Curl downs x 10
reps x 2 sets x O.D

Curls up x 10 reps x
2 sets x OD

Pelvic tilt exercise x

15 SH x 10 reps x 2
sets

Pelvic clock
exercise x 10 reps x
2 sets x O.D

As tolerated

Mechanical
strengthening of the
trunk flexors using
light theraband x 10
reps x 2 sets x O.D

Manual
strengthening of
trunk lateral flexors
x 10 reps x 2 sets x
O.D

Postural deviation Lumbar HMP on the These exercises

as to increased low back area x 20 can help the patient
lumbar lordosis and mins x O.D in increasing the
protruded abdomen awareness and
with low back pain Continuous correcting the
ultrasound x 3 MHz posture. Other
x1.5 w/cm2 x 5 mins exercises such as
x O.D pelvic clock and tilt
are helpful in
Postural correction posture related back
 exercise at wall x pain.
5SH x 5 reps x O.D
Heating modalities
Stretching of the provide relief of pain
lumbar spine in while promoting
prone, quadruped vasodilation for
and standing x good circulation in
15SH x 10 reps x 2 the area
sets x O.D

Home exercise program:

· General and Lifestyle Modifications:

o Engage in physical activity at least 30 to 60 minutes 3x per week such as
walking, Cycling, Running, Jogging, Aerobic dancing, etc.
o Smoking and drinking cessation
o Reduce intake of caffeine drink at least 8 glasses of water instead
o Sleeping hours should at least 6 to 8 hours
o Continue having a healthy meal diet
o Start exercising when the tissue is completely healed
o Remember to stretch and perform breathing exercises before and after
doing home exercise

· Exercises:
o Walking exercises around the house x 30min/day x 3 time per week
o Head lift exercise x 10 reps x 2 sets x OD
o Sit ups x 10 reps x 2 sets x OD
o Pelvic tilt exercises x 10 reps x 2 sets x OD
o Pelvic Bridging exercise x 10 reps x 2 sets x OD
o Drawing in maneuver for at least the whole day
o Abdominal Bracing for at least the whole day
9. Describe the outcome measures used to monitor/progress/discharge this patient
as to validity, reliability, etc. Can the use of the outcome measures be justified or are
there better alternatives? List down valid outcome indicators for monitoring your
patient’s progress using the recommended ICF grading.

OUTCOM RELIABILITY VALIDITY

E
MEASUR
E

Manual “both reliability and validity

muscle are satisfactory for clinical use…” (Hislop)
testing
*Reliability is increased by adhering to the same
procedure for each test (for one or several examiners), by providing
clear instructions to the subject, and by having a quiet and comfortable
environment for the test. (Hislop)

MAPP According to the study conducted by Zubaran,et al., (Maternal

QOL Postpartum Quality of Life questionnaire) is a self-administered
instrument that measures quality of life during the early postnatal period
it is composed of 5 domain and demonstrates convergent validity with
measures of life satisfaction and mood states.

Zubaran, Carlos, Foresti, Katia, Schumacher, Marina Verdi, Thorell,

Mariana Rossi, Muller, Lucia Cristina, & Amoretti, Aline Luz. (2009). An
assessment of maternal quality of life in the postpartum period in
southern Brazil: a comparson of two questionnaires. Clinics, 64(8), 751-
756. https://dx.doi.org/10.1590/S1807-59322009000800007

ICF SCORING
 # OUTCOME DLS ICF SCORING
MEASURE

INTERPRETATION:

IMPAIRME PERFORMANCE
NT AND CAPACITY

PAIN NRS 2 2

LOM ROM 4 4
(Patient ROM are WNL done
actively and passively and
pain free)

MUSCLE WEAKNESS

TRUNK FLEXION MMT 1 1

TRUNK LATERAL FLEXION MMT 1 1

Postural deviation Postural 3 3

(Patient posture is essentially Screening
normal)

MEAN SCORE: 2.5 2.5

INTERPRETATION: MILD IMPAIRMENT AND

DIFFICULTY

10. Discuss the patient's prognosis (medical prognosis and rehabilitation potential)
including any personal, social and environmental factors that can affect the prognosis
(i.e. motivation level, work status, education level, family support, etc.). Would you
expect the patient to have residual signs and symptoms at the end of the course of
treatment? When do you expect your patient to be discharged and what discharge
criteria will you use? What are your plans for community re-integration for this patient (if
any)?
Favorable Unfavorable
● Patients age ● (+) Depression
● Patient is independent in all aspect of her ADLs ● (+) Urinary
● Has own weaving business incontinence
● Ambulatory s assistance and assistive device ● Smoke and drink
● Not in apparent pain and respiratory distress occasionally
● postural and gait deviations ● Single mother
● Has one stay-in house help ● Not financially stable
● Sedentary lifestyle
● Patient is very
anxious in about
participating in
physical therapy

Patient prognosis is good because according to Kisner a common

complaint during third trimester of pregnancy may include low back pain and frequent
urination; problems like these can be treated by physical therapy interventions if the
main cause of the problem is muscle weakness or imbalances furthermore according to
literatures urinary incontinence may last up to 12 months even after delivery comparing
it in the patient presentation the duration of the leakage is still under normal
circumstances and can still be considered that it has good prognosis. Aside from that,
the patient doesn’t present with any comorbidities that may hinder the treatment
however, presence of depression which has been diagnosed 3 years ago did not
specify if this is under medical supervision with medication or not. Careful monitoring of
the patient’s condition and provide modification as to treatment can decreased the
psychological impairment. More importantly even though the patient has these
conditions she can still perform all aspect of her ADLs which includes being a worker at
her own weaving business and being a single mother to 2 children.

References:

Romano, M., Cacciatore, A., Giordano, R., & La Rosa, B. (2010). Postpartum period:
three distinct but continuous phases. Journal of prenatal medicine, 4(2), 22-5
Kisner, C., &amp; Colby, L. A. (2007). Therapeutic Exercise (6th Edition). Philadelphia:
F.A. Davis Company.
Kegel Exercises. (n.d.). SpringerReference. doi:10.1007/springerreference_44319
Hoffman, B., Whirtridge, W & et.al (2012) Williams Gynecology (2nd edition). McGraw-
Hill Companies
Fogel, C. I., R.N., B.S.N., M.S., & Woods, N.F., R.N., M.N., PhD. (1981). Health care of
women. A nursing perspective, Mosby

GOOD LUCK AND GOD BLESS!!!