systemic tx -- cardiovascular treatment & pregnancy Flashcards
atherosclerosis symptoms when?
likely no symptoms present until the vessel is blocked or narrowed enough to alter blood flow or thrombus/embolism formation.
atherosclerosis @ coronary arteries
Arteries in the heart may cause angina or heart attack. Symptoms: chest pain, difficulty breathing, restlessness, dizziness, anxiety.
atherosclerosis @ carotid? arteries
Arteries that supply head/brain, may experience TIA or stroke if embolism occurs (weakness, numbness, slurred speech).
peripheral arteries?
Arteries in the arms/legs patient may experience pain in arms or legs and intermittent claudication (peripheral vascular disease)
aneurysm
If vessel walls become weakened, aneurysms may occur – potential to rupture vessel, excessive bleeding and potential organ damage or fatal. Sudden severe pain in head or abdomen (brain, aorta)
CO
SV x HR
BP
CO x TPR
TPR
Size of the lumen of the vessel (vessel diameter)
Blood vessel length
Blood viscosity
normal BP
less than 130 systolic
less than 85 diastolic
prehypertension (high normal)
130-139 systolic
85-89 diastolic
stage 1 (mild) hypertension
140-159 systolic
90-99 diastolic
stage 2 (moderate) hypertension
160-179 systolic
100-109 diastolic
stage 3 (severe) hypertension
180-209 systolic
110 diastolic
stage 4 (extreme) hypertension
210+ systolic
120+ diastolic
hypertension symptoms when?
Asymptomatic until complications develop
May Be Variable depending on blood vessels affected
Possible dizziness, light-headedness, HA, fatigue, facial flushing and personality changes can all occur
Possible edema in lower extremities
primary vs secondary hypertension
secondary = Secondary to other condition-cancer, kidney disease, pregnancy, thyroid/sudden severe onset.
clinical manifestations, history
Fatigue/laboured breathing
Headache during exercise
Intermittent claudication
Chest pain
History of heart attack/heart disease
other factors
Client unwilling to make changes to health
Unknown health status
Congestive heart failure (need to speak with Dr)
when refer to doctor?
Undiagnosed hypertension
Stage 3 or 4 hypertension: wait 10-15 minutes and retake BP reading, (unless patient is displaying symptoms such as headache, anxiety, nosebleed-then immediate Dr. referral.)
—>
If still elevated on the second measurement, refer for immediate medical attention, especially if the diastolic is over 120
when 911?
**Call 911 if patient is experiencing shortness of breath, chest pain, difficulty speaking, etc
hypertension risk factors
Age
—> Anyone over the age of 45
—> Over half the population over 65 has some degree of hypertension
Family history
Diabetes
Obesity
Lifestyle
—> Smoking/diet/stress/sedentary
if new client presents hypertension risk factors?
**If new client presents with risk factors, take BP reading before tx
precaution, CI – CVD (“central”)
DON’T increase the work of the heart:
e.g. by dramatically increasing venous return
DON’T increase the risk of local tissue damage:
e.g. XFF can cause prolonged bleeding in malnourished tissue
DON’T interact with the use of medications: e.g. vasodilators and hydrotherapy
DON’T increase the risk of a secondary systemic complication: e.g. dislodging a thrombus
precaution/CI
tranverse/SEGMENTAL strokes to avoid increasing venous return
no intense techniques (e.g. frictions)
avoid cold hydro if an area is meant to be vasodilated
avoid deep comp to prevent “dislodging” thrombus
other CI
No full body hydro
No prolonged elevation of legs
Precautions-deep neck work, passive stretching of neck-may compress blood vessels
Modify prolonged, repetitive, broad, full body strokes to short segmental
No full body lymphatic drainage.
Avoid painful or stimulating techniques
(increase SNS = increase BP)
position? hypertension/CVD
May need to limit time in prone, modify depth of pressure, and limit painful, stimulating techniques depending on how stable BP is.
i.e.
Goal is to decrease work to the heart-limit anything that will increase heart rate, or blood return to the heart-use shorter strokes, limit elevation of legs
HYDRO? hypertension/CVD
No full body hydro
acceptable techniques? hypertension, CVD
MFR depending on tissue health
PROM, Stretches, Joint mobs if indicated
Swedish/petrissage techniques modified to short and segmental strokes
stable/managed stage 1-2 hypertension?
Most patients with Stage 1 or 2 hypertension will require little to no modifications if their BP is stable and managed.
Hx, hypertension/CVD
Is their hypertension managed and stable
current BP?
meds?
regular checkups?
fitness?
general health?
systemic conditions?
pain/claudication?
sleep position/activity?
respiratory changes?
doctor cleared massage?
current symptoms?
headache?
signs of CHF?
Left sided=breathing difficulties
Right sided=systemic edema (need Dr. consent to treat)
observations?
Edema,
varicosities,
facial colorations,
extremity coloration (skin color: flushing, cyanosis),
sweating,
labored breathing,
tissue health (dry, cracked skin, fragile/compromised skin)
palpation?
Pulses – assess if they are normal, absent, dimished, bounding (compare bilaterally),
Edema (pitting vs non pitting), location/extent
Skin – temperature (extremities and core), sweating
also check for
TOS/neurological
MI vs TrP referral
MI refers to shoulder, jaw, down arm and can along back and sternum.
Trigger points can also refer to these areas (pec mj/mn, serratus anterior, scalene, levator scapula etc)
special tests for central CV conditions
blood pressure and respiratory status
special tests for peripheral vascular conditions
capillary refill test,
Allen’s test,
Manual compression test,
Pulses,
Leg raise for varicose veins,
Pitted edema test,
Homan’s test
How to find pulses
Use the pad of your finger, not the tip
Don’t push too hard or you can occlude the vessel
one possible technique to palpate pulse more effectively
Sometimes, using a number of fingers along the course of a vessel, and applying firmer pressure with the distal fingers will allow you to feel the pulse better in the proximal fingers
RATING PULSE
“2/2” if strong
“1/2” if weak
“0/2” if absent
ulnar pulse
on the medial side of the wrist find the pisiform bone. Roll your finger laterally from this and the artery runs along here. Harder to find than the radial artery.
femoral pulse
along the inguinal ligament, about halfway from the ASIS to the pubic tubercle.
anterior tibial pulse
feel along the anterior shin lateral to the tibia. It is easiest to feel halfway down the shin. Branch of the popliteal artery
posterior tibial pulse
on the medial side of the ankle find the medial malleolus. Roll your finger towards the angle of the heel and feel for the pulse.
dorsal pedis pulse
on the top of the foot about 1/3 of the way to the toes, feel laterally to the extensor hallucis longus tendon. The artery runs along side the tendon. This is a branch of the popliteal artery.
common carotid pulse
only check one at a time. Find the bottom of the lateral edge of the thyroid cartilage. Then feel 1-2 cm lateral to that.
external carotid pulse
only check one at a time. About 2 cm anterior of the scm along the fold of the jaw line.
temporal pulse
find the top part of the ear that is attached to your face (about eye level) and about 1 cm anterior is the pulse.
note positions
supine, semi-fowler
side-lying?
__
class 2
if hypertension
Don’t increase heart rate or venous return
Stage 1 and 2 require little mods
USE CLINICAL REASONING
Modify position and techniques if BP unstable, higher on spectrum or complex/unknown health history
if arterial insufficiency
SKIN INTEGRITY
Increase peripheral circulation
Avoid restricting blood flow to affected area
Consider secondary health
concerns
if venous insufficiency
Blood may pool in periphery.
Increase circulation-increase venous return.
Consider secondary health concerns. (hypertension, edema and causes)
diseases affecting bv
Diseases affecting the blood vessels usually result in some form of peripheral vascular disease (PVD).
peripheral vascular disease can affect ___
PVD can affect the arterial, venous or lymphatic circulatory systems.
occlusive diseases of bv
commonly d/t?
Occlusive diseases of the blood vessels are a common cause of disability and usually occur as a result of ATHEROSCLEROSIS
Other causes of arterial occlusion include trauma, thrombus or embolism, vaculitis or vasomotor disorders (Raynaud’s).
e.g. occlusive disease of bv
Thromboangitis obliterans
Arteriosclerosis obliterans
Arterial thrombosis
Arterial embolism
THROMBOANGITIS OBLITERANS (BUERGER’S DISEASE)
Inflammatory lesions of the peripheral blood vessels are accompanied by thrombus formation and vasospasm occluding blood vessels.
A vasculitis, i.e. an inflammatory and thrombotic process, affecting both arteries and vein, primary in the extremities
eventually OBLITERATING (destroying) small and medium vessels of the feet and hands
thromboangitis obliterans etiology
risk factors?
unknown
smoking
—> Usually found in men younger than 40 who smoke heavily
thromboangitis obliterans SSx
Symptoms are episodic and segmental (i.e. come and go intermittently over time and appear in different, asymmetrical anatomic locations)
Intermittent claudication in the arch of the foot or the palm of the hand is often the first symptom
Symptoms include pain at rest, edema, cold sensitivity, rubor (redness of the skin from dilated capillaries under the skin), cyanosis, and thin, shiny, hairless skin (trophic changes) from chronic ischemia
thromboangitis obliterans, possible first symptom
Intermittent claudication in the arch of the foot or the palm of the hand is often the first symptom
thromboangitis obliterans, tx goal e.g.
Include increasing circulation to the hand or foot
ARTERIOSCLEROSIS OBLITERANS
Proliferation of the intima causes complete obliteration of the lumen of the artery
—> (buildup in tunica intima)
A.k.a. peripheral arterial disease
Most common occlusive disease (about 95% of cases)
arteriosclerosis obliterans AKA
A.k.a. peripheral arterial disease
Most common occlusive disease (about 95% of cases)
ATHEROSCLEROSIS??
arteriosclerosis obliterans
???
arteriosclerosis obliterans etiology
?
Associated with diabetes mellitus
Risk factors include smoking, hypertension, hyperlipidemia, obesity, and diabetes
arteriosclerosis obliterans – demographics
Most often seen in elderly patients
arteriosclerosis obliterans, SSx
Bilateral, progressive INTERMITTENT CLAUDICATION is usually present in muscles
Primary symptom may be a sense of weakness or muscular “tiredness”, both the pain and weakness/fatigue are relieved by rest
Pain at rest indicated more severe involvement; may be relieved by dangling limbs (usually leg) over the edge of the bed to use gravity to encourage circulation (dependent position)
dependent position
good for arterial insufficiency
bad for venous insufficiency
?
dependent position would ___
this dependent position would relieve arterial pain but would increase symptoms of a DVT (venous)
arteriosclerosis obliterans, tx goals
Preventive skin care is a primary goal in treatment; avoid minor injuries, infections and ulceration
Exercise to increase collateral circulation and improved function
collateral circulation define
“Collateral circulation is alternate or ‘backup’ blood vessels in your body that can take over when another artery or vein becomes blocked”
diabetic neuropathy vs arteriosclerosis obliterans
Diabetic neuropathy with diminished sensation of the toes or feet often occurs, predisposing the patient to injury or pressure ulcers that may progress because of poor blood flow and ongoing loss of sensation
arteriosclerosis obliterans — clinical manifestations
Pain on activity-predicable onset, stops when activity stops. (intermittent claudication)
Pain on elevation, relieved on dependent position (legs up vs legs down)
Lack of circulation to extremities-skin integrity, diminished pulses
arteriosclerosis obliterans, other factors
Long term, unmanaged hypertension
Diabetes
few notes to recall:
why does ischemia cause pain?
why does diabetes damage small vessels?
“Ischemic pain occurs due to a lack of oxygen and nutrients reaching tissues, leading to the buildup of metabolic byproducts like lactic acid, which activates pain receptors and signals pain to the brain”
“Excess blood sugar decreases the elasticity of blood vessels and causes them to narrow, impeding blood flow. This can lead to a reduced supply of blood and oxygen”
“Diabetes damages small blood vessels (microvascular disease) due to chronically high blood sugar levels, which lead to thickening of the vessel walls, reduced blood flow, and increased risk of complications in organs like the eyes, kidneys, and nerves.”
arterial thrombosis vs atherosclerosis?
CHATGPT, consider potential mistakes
“Arterial thrombosis, a complex process, typically originates from atherosclerotic plaque disruption, leading to platelet activation, aggregation, and fibrin formation, ultimately forming a thrombus that can obstruct blood flow”
Calf Cramps & Arterial Pathologies
– A consideration in differential diagnosis
“The therapist must be aware that spasms and cramps can be caused by pathologies
and medication. In these cases, treatment modifications or referral to a physician may
be indicated. For example, calf muscle cramps may occur with arterial disorders, such as:
Acute arterial occlusion due to a thrombus or embolism;
Chronic arteriosclerotic vascular disorder due to arterial narrowing and fibrosing, which is frequently associated with diabetes mellitus and with the aging process;
Other causes:
Deep vein thrombosis:
Diabetes – neuropathic pain from damaged nerves
Muscle cramp- exertion/dehydration/fatigue
Intermittent claudication is due to ischemia.
Pain and cramping are often noted when the client is walking. They diminish slowly
with rest. …”
chronic arterial insufficiency — note ___
pulse decreased/absent
colour pale, esp elevation, red in dependent position
temp cool
edema absent/mild
skin changes = trophic changes
ulceration = at toes, if at all
gangrene = possible
chronic venous insufficiency — note ___
pulse normal, but difficult to palpate through edema
colour normal, or cyanotic (dependent position)
temp normal
edema = yes
skin = possible stasis dermatitis, brown pigmentation
ulceration? @ ankles if present
gangrene = no
“Venous ulcers most often form around the ankles”
Why?
?
trophic changes, e.g.
thin, shiny skin
loss of hair in extremities, esp hands/feet
nails thickened/ridged (clubbing)
arteriosclerosis obliterans, Hx
pain during activity (legs usually), underlying cardiovascular ie. Hypertension, or history of heart disease. Other health concerns ie. Diabetes.
Ddx (from venous condition) = Pain if limb is elevated, and relieved in dependent position
arteriosclerosis obliterans, observation
shiny fragile skin, thickened nail beds, distal ulcers
Palpation-cool to touch
Movement-elevation increases pain
arteriosclerosis obliterans, SPECIAL TESTS
capillary refill
pulse
chronic arterial disease/insufficiency — Tx goals
- Improve local/collateral circulation
- Improve exercise tolerance for ADL’s and decrease the incidence of intermittent claudication
—>
regular, graded aerobic exercise program of walking, cycling, whatever they’re able to do comfortably
(consider compliance) vasodilation by reflex heating - Relieve pain at rest
—>
sleep with the legs in a dependent position over the edge of the bed, or with the head of the bed slightly elevated - Prevent joint contractures and muscle atrophy
—>
active or mild resistance Range Of Motion exercises to the extremities - Prevent skin ulcerations
—>
Educate client in the proper care and protection of the skin, particularly proper shoe selection and fit, avoid use of compression stockings
why potential reduced mm function from arterial insufficiency?
reduce blood flow & nutrients to mm of extremities
Raynaud’s (disease/phenomenon)
Intermittent episodes of small artery or arteriole constriction of the extremities causing temporary pallor and cyanosis of the digits (usually fingers)
These episodes occur in response to the cold temperature or strong emotion (anxiety or excitement)
removing blood supply to hand would cause paresthesia?
Why?
CHATGPT (potential errors)
“Yes, cutting off circulation to a hand can cause paresthesia (a tingling, prickling, or burning sensation) because the peripheral nerves, which rely on blood supply for oxygen and nutrients, are deprived of these essentials, leading to nerve dysfunction”
Raynaud’s, mechanism/steps
Arterial vasospasm in the skin
constriction
pale cold skin
blood pools in surrounding tissues
bluish/purplish skin
white
red (as vessels relax and blood flows in)
warm red skin (may experience throbbing, swelling and paresthesia)
Raynaud’s disease vs phenomenon
Raynaud’s disease: primary condition, vasospastic disorder (idiopathic)
Raynaud’s phenomenon: secondary to another disease or underlying cause
Raynaud’s disease, demographics/etiology
80% of people with it are women aged 20-49 years old
Idiopathic; seems to be caused by hypersensitivity of digital arteries to cold, release of serotonin, and congenital predisposition to vasospasm
Raynaud’s phenomenon, demographics/etiology, risk factors
Predicted that 10-20% of the general population has this; usually women between 15-40 years old
Secondary to other conditions (buerger’s, connective tissue disorders, hidden neoplasms); has been known to be precipitated by use of pharmacological med’s and by exposure to temperature changes (warm to cool/cold), also injuries to hand (repetitive stress e.g. keyboarding, using crutches)
Nicotine constricts small blood vessels; smoking can trigger attacks in people predisposed to this phenomenon
Raynaud’s disease accounts for ____ of cases
accounts for 65% of people affected by Raynaud’s
is Raynaud’s a cause for serious concern?
“More annoying than medically serious”
Raynaud’s, Hx, important notes
Is this condition primary or secondary
Underlying health concerns if secondary
Current attack
Skin integrity
Triggers-stress, cold
Raynaud’s, Hx Q again
Has this been diagnosed, is it secondary to an underlying health concern
Are you currently having an attack?
What are your triggers?
Is the skin cracked, thin, or ulcerated? (may observe)
Skin integrity is major concern for arterial insuf.
Raynaud’s vs arterial insufficiency
(CHATGPT)
“While Raynaud’s phenomenon involves reduced blood flow, it’s not a form of arterial insufficiency in the same way as Peripheral Artery Disease (PAD), which involves blockage or narrowing of arteries. Raynaud’s is a vasospastic disorder where blood vessels in the extremities, primarily fingers and toes, narrow in response to cold or stress, causing temporary blood flow restriction.”
Raynaud’s, examination
Colour and texture of the skin and nail beds (pallor or cyanosis of the fingers may indicate Raynaud’s)
Palpate temperature, where is it cold
Look for cracks/ulcers/fragile skin
With the pads of your index and middle fingers, palpate the radial
pulse on the flexor surface of the wrist laterally. Compare the volume
of the pulses on each side.
pulse vs arterial insufficiency
Arterial occlusion in the arms is much less common than in the legs. If pulses are markedly diminished or absent, however, consider thromboangiitis obliterans (Buerger’s disease), scleroderma, or, possibly, a cervical rib.
If arterial insufficiency is suspected, palpate also 1) for the ulnar pulse, on the flexor surface of the wrist medially, and 2) for the brachial pulse, in the groove between the biceps and triceps muscle above the elbow.
Allen test (arterial insufficiency)
Since the normal ulnar artery is frequently not palpable, the Allen Test may be useful. It tests the patency of the ulnar and radial arteries in turn.
Ask the patient to rest his/her hands on the table. Place your thumbs over their radial arteries and ask them to clench fists tightly. Compress the radial arterial firmly, then ask the patient to open hands into a relaxed position. Observe the colour of the palms. Normally they should turn pink promptly. Repeat occluding the ulnar arteries.
Persistence of pallor when one artery (e.g. the radial) is manually compressed indicates occlusion or compromise of the other (e.g. the ulnar).
capillary refill test (arterial insufficiency)
Check the finger nails for cracked nails and skin integrity first.
Then apply pressure on nail bed for 10 seconds. Release and observe the color of the nail bed. The color should return within 7-10 seconds. If the color remains white longer then there is arterial insufficiency.
arterial insufficiency – Tx MODIFICATION
Avoid areas where skin is compromised
No elevation of affected limb
Modify temperature (ie CAB), no temperature extremes. Warm/cool
Modify stimulatory/painful techniques during attack. (Raynauds)
E.g. tx goals, arterial disorders/insufficiency
Decrease FIDs of attack
Increase peripheral circulation
Manage stress if it is a trigger
Patient education to manage triggers (e.g. cold/stress)
tx focus
Prone- (unless unmanaged hypertension)
Interscap
Swedish arm to hand
Supine-’glitchy bits’ (?)
Scalenes/pec minor/ subclavius
Brachialis
Pronator teres
Carpal tunnel
class 3
…
edema, considerations
What is the cause? We need to know the cause before we treat the edema.
-trauma? (what stage is the injury)
underlying health concerns (CHF, liver/kidney issues)
Deep vein thrombosis
Infection
Cancer
edema, Hx
general health history,
cardiovascular health,
kidney or liver diseases,
injuries (when was the injury, MOI, is the joint affected),
infections,
surgery,
pregnancy (BP, has md or midwife assessed)
how long they have had it,
have they seen a doctor,
are they cleared for treatment,
are they on medication,
do they use any devices to assist with swelling (stockings/bandages etc),
are they seeking other treatments?
edema, observation
compare bilaterally for swelling, postural observation, gait, ROM to assess affected joints, skin quality/tissue integrity, color of tissue, area affected
Palpation: tenderness, heat, coolness, pulses (may not be able to feel due to swelling), density/quality of edema (firm, boggy, taut)
Movement: ROM for joints affected
Neurological: nerve compression may be a factor with swelling
Referred pain: may be due to nerve compression
edema, special tests
Special tests: girth measurement of affected area (test bilaterally if applicable), pitted edema test.
consider these types of venous disorders
Acute Thrombophlebitis
Chronic Venous Disorders
-chronic venous insufficiency
-varicose veins
Thrombophlebitis
Thrombophlebitis is the swelling of a vein due to a blood clot. Clots may be as long as 20 inches along the wall of the vein.
This is not a condition that can be treated by RMTs. The risk of dislodging the clot poses serious complications.
DVT / thrombophlebitis risk factors
Prolonged immobilization
Trauma, especially in the legs or pelvis
Surgery to legs
History of thromboembolism
History of heart disease
Pregnancy and post partum state
Oral contraceptive pill
Diabetes mellitus
Clotting disorders
Nursing home residents
DVT, thrombophlebitis, SSx
-heat swelling redness along course of vein
-pain at rest, worse on elevation or movement
-throbbing deep pain
-look for risk factors
-can be asymptomatic
-may be feverish
DVT, Hx
Have they been diagnosed,
have they been cleared of a dvt,
associated calf cramping/intermittent claudication,
any recent surgery/immobilization/trauma to legs,
pregnant/post partum,
heart disease,
health history (DVT risk factors),
DVT, observation
edema, redness cord like swelling.
Palpation: pain, heat, swelling,
Neurological: compression from edema possible
Referred pain: intermittent claudication (?)
DVT, limb elevation?
???
Movement: pain increase with elevation, pain does not decrease in dependent position.
other source:
(regarding DVT) “Elevation: Elevating the legs can help to instantly relieve pain.”
(Chatgpt) “Elevating the legs can actually help reduce pain and swelling associated with a DVT (deep vein thrombosis) by improving circulation and decreasing pressure in the veins”
DVT, thrombophlebitis, special test
Homan’s test (rule out dvt)
note that sensitivity & specificity is poor
—> not good diagnostic value
if suspecting DVT?
Check with Dr. if patient has current DVT diagnosis
If you suspect a DVT, immediate medical referral
—> (Refer to MD for diagnosis if you suspect DVT is present)
DVT, CI
NO local massage or ROM to affected limb
No heat distal or immediately proximal
Recent femoral fracture-no treatment to lower limbs (bilateral)
Varicose veins
Varicose veins are swollen, twisted, and sometimes painful veins that have filled with an abnormal collection of blood.
varicose veins, clinical manifestations
Twisted, bulging blue lines running down all or part of a leg
Legs that ache or become tired and weak, especially after long periods of sitting or standing
Restless legs or legs that are so uncomfortable that a person has difficulty standing on both feet at once
Burning or itchy skin on the legs
Legs and/or ankles that become swollen and possibly have brownish pigmentation
Leg cramps, especially in calf muscles often occur at night
varicose veins, Hx
Family history,
have they been diagnosed,
have they been cleared of a dvt,
have they had recent medical intervention to vv,
are they painful/sensitive to touch,
symptoms they experience,
how long have they had them,
associated calf cramping/intermittent claudication,
history of recent surgery/immobilization,
pregnant/post partum,
heart disease,
health history (DVT risk factors).
varicose veins, observation
Observation: look for twisting, bulging, inflammation, edema
Palpation: pain, heat, swelling
painful/skin integrity?
Movement: would not do with suspected DVT. (?)
Neurological: compression from edema possible
Referred pain: intermittent claudication or nerve compression
Special tests: Homan’s test (rule out dvt), leg elevation
Leg Elevation (test for varicose veins)
Elevate legs
Observe whether “normal” bulging of vein disappears
Varicose veins will not disappear completely because the faulty vein has stretched beyond its normal diameter and length
varicose veins, CI/precaution
NO deep specific techniques if tissue is dystrophic
NO local massage if the varicose veins are painful
NO massage 24 hours post medical treatment to varicose veins (i.e. saline injections, surgery etc) until approved by MD
NO massage over varicosity if there is no diagnosis of varicosity of thrombophlebitis but the client presents with DVT symptoms
varicose veins, consider also ____
Underlying cardio issues, hypertension, CHF
…
pregnancy
pregnant patients & professionalism
Pregnancy may be difficult to achieve, unwanted, terminated willingly or unwillingly.
You may not be aware of this person’s experience around pregnancy, whether they be your friends, classmates, instructors or patients.
first trimester length
weeks 1-12
1st trimester SSx
Nausea & vomiting (morning sickness); most common is first trimester but can continue through the pregnancy
1st trimester, excretion
Frequent urination: due to progesterone which relaxes the smooth muscle of the bladder
Constipation: progesterone causes relaxation of smooth muscle
1st trimester, BP
Blood pressure drops: progesterone causes relaxation of smooth muscle in vessels
1st trimester, breasts
Breast changes: increased fullness, tenderness, sensitivity
why increased fullness?
“During the first trimester, breasts often feel full and tender due to surging pregnancy hormones like estrogen and progesterone, which cause increased blood flow and breast tissue growth in preparation for breastfeeding.”
(AI)
1st trimester, musculoskeletal changes (esp CT)
Musculoskeletal changes: due to relaxin; affects connective tissue, especially ligaments & joint capsules
1st trimester, other SSx
Taste and Smell are altered in the early stages of pregnancy
Mood swings; most common in the first trimester. Extreme fatigue increase feelings of irritability and depression. Anxiety about pregnancy is common.
what is a common cause of anxiety in 1st trimester
(Anxiety about pregnancy is common.)
Greatest risk of miscarriage is in the first trimester
2nd trimester, length
Weeks 13-27
2nd trimester, edema & hypertension
Edema: mechanical – weight of uterus on inguinal area causes edema in legs; may also be due to high BP (pre-eclampsia)
Hypertension: pregnancy induced – a.k.a. Pre-eclampsia
important note about position in 2nd trimester
Supine hypotensive syndrome: due to compression of inferior vena cava by fetus in supine position
why is there shortness of breath in 2nd trimester
Shortness of breath:
Mechanical – uterus pushes abdominal contents up into diaphragm, impeding function;
Physiological: 20% increase in required oxygen due to increased basal metabolic rate
2nd trimester, pain
Backache
Abdominal pain
Pubic symphysis pain
2nd trimester, backache
Backache: lumbar pulled forward by weight of belly; lumbar & pelvic joints are loose (relaxin) & rely on muscles for support
2nd trimester, abdominal pain
Abdominal pain:
—> uterine ligament referral;
—> diastasis recti – separation of rectus abdominus at linea alba.
what to do if unexplained abdominal pain?
Refer to physician for unexplained abdominal pain.
2nd trimester, pubic symphysis pain
due to relaxin
2nd trimester, varicose veins & skin changes
Varicose veins: compression of vessels at inguinal area
Hemorrhoids: straining due to constipation
Stretch marks may develop as the body changes
2nd trimester, other SSx
nasal congestion,
nosebleeds,
headaches
why nosebleeds during pregnancy?
“Nosebleeds during pregnancy are normal and usually not a cause for worry. Most nosebleeds are caused by an increase in blood volume and hormonal changes.”
“Nosebleeds during pregnancy are common due to hormonal changes that increase blood volume and blood flow, leading to more fragile blood vessels in the nose that are prone to bursting.”
(AI)
why nasal congestion during pregnancy (E.g. 2nd trimester)
“Experts aren’t entirely sure why it happens, but in some people, higher levels of hormones cause the receptors to respond by widening blood vessels in your nose and creating mucus. This can block it and make it hard to breathe.”
3rd trimester, length
Weeks 28-40
3rd trimester & gestational diabetes
acquired insulin resistance, causing increased blood glucose levels
why gestational diabetes
“Gestational diabetes mellitus occurs only in women during pregnancy.”
“Although the exact cause is unknown, the prevailing theory is that the placenta—the organ that delivers water and nutrients to the fetus—produces hormones that block the mother’s ability to use insulin effectively.”
3rd trimester, gestational diabetes & ketoacidosis
(ketones)
(secondary to diabetes)
“your liver breaks down fat for fuel, a process that produces acids called ketones.”
how common is gestational diabetes?
“Every year, 5% to 9% of U.S. pregnancies are affected by gestational diabetes. Managing gestational diabetes can help make sure you have a healthy pregnancy and a healthy baby.”
gestational diabetes risk factors
“Being overweight or obese.
Not being physically active.
Having prediabetes.
Having had gestational diabetes during a previous pregnancy.
Having polycystic ovary syndrome.
Having an immediate family member with diabetes.
Having previously delivered a baby weighing more than 9 pounds (4.1 kilograms)”
3rd trimester & nerve compression syndromes (neuropraxia)
TOS
CTS
may develop, due to arm & hand edema
3rd trimester, also back pain
(lumbar pulled forward by weight of belly)
3rd trimester, SIJ discomfort, sprain/RSI
also note HT mm @ pelvis
intensely painful; walking can be difficult
Pelvic discomfort: loose joints causing tight muscles
note loose joints/ligs vs hypertoned mm
(as expected)
“A common question I hear from my patients and clients who have been diagnosed with Ehlers Danlos Syndrome (EDS) or Hypermobility Spectrum Disorder (HSD) is, “If my joints are so loose, why do I feel so tight?” A feeling of tightness of the muscles, often resulting in pain and discomfort is very common among those with these diagnoses. EDS and HSD cause increased laxity of the ligaments, which causes “looseness” of the joints. The brain will do whatever it can to attempt to stabilize the joints.”
“One of the things the brain can do is instruct the muscles surrounding the loose joints to increase their tone. This increased muscle tone can help improve joint stability. However, this can also result in the muscles staying in a hypertonic state. Hypertonic muscles do not fully relax but instead stay “on” all the time.”
3rd trimester, possible cause of leg cramps
ischemia
poor arterial function?
(due to blocked circulation, esp @ inguinal lig)
or possibly DVT
3rd trimester, costal margin pain
Costal margin pain: as uterus compresses lower ribs
3rd trimester, frequent urination/incontinence
PROGESTERONE (smooth mm bladder)
BUT ALSO:
—>
increased pressure on bladder
(increased size of uterus)
3rd trimester, sleeping difficulties
Insomnia and restlessness: Heartburn, fetal movement and the need to urinate frequently all contribute to sleep difficulties
why heartburn during pregnancy?
“Heartburn is common during pregnancy because of hormonal changes and the growing baby’s pressure on the stomach.”
(AI)
uterine ligaments & referral pain
As the uterus grows the ligaments which suspend it in the pelvic cavity are stretched, and can be a source of referred pain.
muscle tension, TrP & referral
As the connective tissue in the body is softened by relaxin, the joints become more loose & unstable, so they rely on muscular support for stability.
round ligament of uterus, referral
to anterior/medial thigh & lower abdomen
broad ligament of uterus, referral
to posterior hip & thigh
sacrouterine (uterosacral) ligament, referral
area over sacrum
positions to avoid after 1st trimester
supine & prone
why avoid prone after 1st trimester
Lying prone increases intrauterine pressure, and further stresses already taxed uterine ligaments (esp. Sacrouterine) and lumbar joints
Prone position may also be uncomfortable on tender breast tissue
also
—> There is increased mucous production in pregnancy, so the patient may become uncomfortably congested in prone
what if patient still wants prone treatment after 1st trimester?
Adjustable pillow systems can allow for prone treatment in most healthy pregnancies
why avoid supine after 1st trimester
The weight of the uterus rests on the inferior vena cava (AND AORTA), resulting in low maternal blood pressure & decreased maternal & fetal circulation (supine hypotensive syndrome)
Other symptoms include uneasiness, dizziness, SOB
how long can patient be in supine after 1st trimester?
what can they do if they want to be supine for longer?
For patients with healthy pregnancies, it is usually ok for them to be supine for 2-5 minutes without risk
You can place a pillow under the right side of the pelvis to shift the weight off the IVC, for extended supine positioning
how about semi-fowler position after 1st trimester?
Semi-fowlers position offers a safe alternative to supine treatments
best position during pregnancy, esp after 1st trimester
Side-lying is the recommended position for massage treatment
Minimizes strain on uterine ligaments
Prevents increased intrauterine pressure
Ensures placental & fetal circulation in high risk pregnancies
Also
—> Prevents increased sinus pressure & congestion
which side lying is best during pregnancy?
LEFT
Most patients can lie on either side for treatment, although left side-lying allows maximum maternal cardiac functioning
pregnancy, CI/precaution
Be cautious with joint mobilization due to the effects of relaxin
Avoid deep massage to the low back, sacrum and abdomen in the first trimester (Due to the greater risk of miscarriage -although there is no evidence of massage increasing the risk of miscarriage)
Be mindful with fascial techniques due to its stabilizing role
sudden change in BP?
Massage is contraindicated if a sudden change in blood pressure is noticed - refer to MD or midwife
patient with GD?
If patient has GD - ensure they have eaten prior to massage
systemic hydro?
Avoid systemic hot hydro that may change increase maternal temperature
if treating supine briefly, or with a pillow
If patient feels unwell in the supine position during the second or third trimester change positions or discontinue treatment
pregnancy & blood clotting
Be aware of the increased risk of blood clots during pregnancy:
A patient’s blood clotting capacity increases 4-5 times normal to prevent potential hemorrhaging during delivery. This process also increases the potential for developing BLOOD CLOTS.
pregnancy, clots vs veins
Clot formation is greatest in veins in which blood is moving slowly or is stagnant.
common veins for clot (thrombus) formation
iliac,
femoral
& saphenous veins,
due to reduced venous return caused by the fetus blocking blood flow at the inguinal area
what to AVOID if concerned about clots
what to do?
AVOID deep treatment to the medial side of the leg
and refer to a physician
some acceptable JM
“Monkey Tail” - Help patient with posterior pelvic tilt
—>
Sacral glide with pelvic rotation (maintain the gain while they releases rotation, & continue) to decrease anterior pelvic rotation
“Jam-jar” to mobilize SI joint (move ileum on sacrum) or to help correct anterior pelvic rotation
acceptable MFR
Lumbo-sacral decompression - Cross-hands, iliac crest and thorax
pregnancy & GSM
Slow petrissage techniques to back, glutes, legs
class 2
Pregnancy & posture
Exercise & pregnancy
—> Diastasis Recti
—> Kegel exercises
Assessment and Treatment Planning
pregnancy posture
thoracic kyphosis
lumbar lordosis
APT
tight short mm:
cervical extensor
lumbar extensor
stretched weak mm:
thoracic extensor
hamstrings
exercise vs pregnancy
Regular exercise during pregnancy is encouraged as it has many positive benefits:
Improves mood and reduces stress
Helps with appropriate weight gain
Promotes better sleep
Improves energy levels
Increases muscle strength and endurance
Helps build stamina for labour and delivery
Speeds up recovery after labour and delivery
exercise vs pregnancy, what to keep in mind
If you are new to exercise, talk to a health care provider first. Start with shorter sessions and easier activities and gradually increase until you are exercising for 30 minutes per session
If you were active before pregnancy, you can continue with your usual activities and make changes as needed
Weight training is safe as long as the resistance is light to moderate. Heavy weights can stress muscles or ligaments
Do not exceed normal joint movement or overstretch because of relaxin
Exercise at a moderate intensity: use the talk test to make sure you are exercising at an appropriate intensity
After the fourth month of pregnancy, avoid exercising on your back for prolonged periods
To prevent pubic symphysis pain, avoid front & side lunges & single-leg stance
Keep cool and hydrated. Avoid exercising outside on very hot days. Drink lots of water before during and after exercise
Talk to your healthcare provider if you experience symptoms after exercise such as vaginal bleeding, dizziness, contractions or swelling pain and redness in the calf of one leg
diastasis recti
separation of the rectus abdominis muscles at the mid-line (linea alba)
“Diastasis recti (rectus diastasis) or divarication of the recti is a stretching of the linea alba with abnormal widening of the gap between the two medial sides of the rectus abdominis muscle (increased inter-recti distance).”
testing for diastasis recti
supine, knees bent; place fingers across linea alba; do a small abd. curl; palpate soft area – how many fingers fit? (1 or 2 is normal)
AVOID these exercises if diastasis recti
Avoid traditional crunches
Avoid twisting crunches
correcting diastasis recti – exercises that may help
Strengthen Transverse abdominal muscles
pregnancy & kegel exercises
Strengthening exercises for the pelvic floor
Better bladder control to prevent incontinence
Helps to prevent prolapse
kegels vs pelvic organ prolapse (“POP”)
“If you have a prolapse of the bladder (cystocele) or uterus (uterine prolapse), Kegels can be very effective for managing POP.”
pregnancy, Hx
General health? Health of pregnancy?
Trimester?
First pregnancy?
Complications with previous pregnancies?
Major symptoms- Nausea, vomiting, swelling, fatigue, headaches …etc
Blood pressure? Pre-eclampsia? Gestational Diabetes?
How have ADLs been affected?
pregnancy – assessing pain, esp musculoskeletal pain & HA
Backache: check posture – rounded shoulders? enlarged breasts? excessive lumbar lordosis?
Hip pain: check posture – ext. rot’d hips? belly carried forward? is it SI joint pain?
Leg cramps:
—> belly carried forward (gripping in feet)? (postural)
—> big belly (compressing inguinal area)? (vascular)
Foot pain: flat feet (relaxin)? excessive weight gain?
Headaches: head forward? rounded shoulders? hormones??
pregnancy – assessing systemic conditions
Blood pressure: gestational diabetes, pre-eclampsia, unusual headache
pregnancy – assessing nerve compressions/neuropraxia
TOS & CTS special tests: is this due to classic nerve impingement, or is it due to postural changes, blood volume changes…
Sciatica?
or piriformis syndrome?
—>
E.g. via actively contracted external rotation @ hip –> leading to HT piriformis
