Wednesday, March 12, 2014

The 40-Week Training Plan: Phase III - Musculoskeletal Changes During Pregnancy

Welcome to the home stretch, ladies!

Third trimester – week 27 to week 40

The guidelines that are out there for this trimester basically go along with those for the second trimester. In addition, this trimester, the recommended extra calorie intake is an additional 450 calories per day, so make sure you are keeping a good calorie balance with expenditure to ensure you are still getting the extra calories your baby needs to grow.

The challenges of continued exercise during this trimester:
1. extra body weight = musculoskeletal pain of all kinds!
2. energy level
3. GI symptoms – return of nausea, worsening reflux, indigestion, constipation
4. frequent urination
5. Braxton Hicks contractions
6. Overheating!
7. Anxiety

Some Tips:
1. Cut back mileage if still running.
2. Short workouts are your friend! They provide you with energy without taking up too much of your free time that you should also spend resting when possible.
3. Try walking and jogging intermittently to maintain exertion without getting out of that elusive "moderate" zone.
4. Plan a run with available pit-stops for those frequent bladder issues.
5. Take up swimming or water aerobics classes if you haven't already. Weightlessness is heavenly, especially during pregnancy, and especially towards the end. It's also a good way to stay cool!
6. DRINK water, water, and more water. (Even though it makes you pee more. Dehydration is not any athlete’s friend, but it is certainly not a pregnant woman’s! And it worsens constipation, so DRINK UP!)
7. Listen to  your body and take care of your mental health, whether that means exercise or rest ;)
How's it going?

32 weeks, 2 days, first senior 24-hour call in the NICU. Last
year at this time I was getting up at 4:30am to run pre-shift.
Now I just got up for a strength workout. And baby was
happy with the extra sleep! :-P
32 weeks, 2 days, and counting… Just two weeks ago, I thought I had gone for my last run, thanks to some lovely pain in my right hip. I took a week off and did a LOT of pool time, and it helped my back and my SAD (seasonal affective disorder, see this old blog post regarding SAD), but I was still waking up every night with AWFUL joint pain in my hip (also in my ankles and knees, but the hip was much worse). Then last week when the snow had finally melted a bit, I decided it would be a shame not to try for one more run to see how things were going. So I went. It was short and slow, but it was okay. So I am gradually back into running but not making myself any promises about how long I will keep hitting the pavement as this pregnancy progresses and as my prenatal body feels more and more foreign and estranged from my triathlete one…and also now that I’m doing 24-hr calls every 4th night in the neonatal ICU.

So here it is folks—the fun of the third trimester! Just 5 weeks in, I have to say, I’ll take GERD and indigestion over joint pains any day! I tried to compare my joint pain while running this pregnant to the pain I experienced running the marathon portion of an Ironman after wrecking my bike. I will just say that it’s a different kind of pain now, and I don’t get a medal for continuing to train through this, which makes my motivation to run a bit different. It’s not that I need a medal to run through pain, but I do want to do what’s best for my baby and for my health so I can be a good mom later, and I’m training for a different kind of race these days ;)

Here are just some of the symptoms that women experience secondary to the musculoskeletal changes during pregnancy:
  1. Back pain
  2. Joint pains
  3. Muscle strains
  4. Nerve pain

Back pain –

Most back pain during pregnancy is due to mechanical factors resulting from altered posture, muscle weakness, joint laxity, and/or vertebral facet joint irritation. Fluid retention within connective tissue can also contribute to the pain. Yay. I haven’t tried one of those pregnancy sleeping pillows yet, but there is a method to the madness, folks. A pillow to support the weight of the uterus and a pillow between the legs relieves much of the pressure on the back, and as always, lay on your side to provide the best blood flow to the baby and to decrease risk of IVC syndrome as we talked about in the 2nd trimester blog post.

What you can do about it (ACOG recommendations to prevent back pain):
Wear low-heeled (but not flat) shoes with good arch support.
Get help when lifting heavy objects.
Place a board between the mattress and box spring if your bed is too soft.
Squat down, bend knees and keep the back straight when lifting.
Sit in chairs with good back support, or use a small pillow to provide support.
Sleep on the side with pillows between the knees for support.
Apply heat, cold, or massage to the painful area.

Pain in joints – pelvis, hips, knees, ankles, shoulders, you name it!

30 weeks... a day I thought was my last run
during pregnancy, but it wasn't :)
While relaxin is to blame for pelvic girdle pain (pain in the 3 joints of the pelvis including sacroiliac joints—it’s ok, it helps your pelvis open more to deliver your baby!), laxity in other joints during pregnancy is actually thought to be due to elevated estradiol and progresterone levels, not relaxin. Along with increased joint laxity, the force across some joints is increased up to two-fold during pregnancy. Yowza. As a person with 2 prior knee surgeries and osteoarthritis from the age of 22, I have to say that I really didn’t expect my knee to make it this long. It’s starting to hurt in the exact spot that used to during college ball, and I know it’s the weight gain and the extra force, coupled with the fact that I haven’t been very dedicated to strength training during pregnancy, so you guys and cyberland as my witness, I am going to have a goal to be more dedicated to strength training these last 8 weeks and see how the joint pain does. It’s partly because of how much strength I feel like I’ve lost in my legs and partly after hearing my new-mom-friends speak about how traumatic labor and delivery was for them because they just felt like their whole bodies were sore for days after labor. I’m sure a lot of that is all the adrenaline and hormones that it takes to push a baby out, but I feel like I owe it to myself to find the time for some strength training to do what little I can for a better delivery for this baby girl. As it goes now, I wake up at night with pain in different joints. Maybe it’s time to finally buy one of those pregnancy pillows? But somehow I feel like it wouldn’t work proportion-wise for a 6’2” woman! Whatever you choose, remember that moderate exercise, light stretching, Tylenol, icing, changes in position throughout the day if you have a stationary job, and time off your feet if you have an active job are all things that are recommended for joint pains during pregnancy.

Leg Cramps and Muscle Strains

Daily exercise to improve circulation and stretching is recommended to prevent leg cramps, but you may get some anyway. Try hot showers, ice massage, and increased hydration to help. For muscle strains, we all know that we’ve had them before, but your body is changing and your technique and form change so much during pregnancy that you are using muscles in different ways. A significant increase in the anterior tilt of the pelvis occurs, causing more use of hip extensor, abductor, and ankle plantar flexor muscles. Stance and gait widen to maintain the movement of the trunk. And I must be doing the weirdest stride ever because I feel it in my hip flexors! Go figure! What all this means is that you may feel some muscles pulling in weird ways, and if something goes too far, remember the kind of race you are running these days- a race for two, not an individual endurance or speed race, and take time for rest and recovery. Ice and foam-rolling for myofascial release and decreased inflammation are your friends because anti-inflammatory drugs are off the market during pregnancy. NSAIDs like ibuprofen are particularly dangerous for baby kidneys, so avoid these. Tylenol is considered safe for pain during pregnancy, but let’s be honest, folks, Tylenol does not work that well for musculoskeletal pain and inflammation, and some studies now link Tylenol use in pregnancy to Autism. (What isn’t linked with Autism these days? Tylenol is still a class B drug, so obstetricians are fine with you taking it for pain during pregnancy if you want to!)

Nerve pain

Numbness and tingling secondary to nerve impingement can be a worrisome and not fun part of trying to stay active during pregnancy. Some people experience carpal tunnel syndrome (fluid retention during pregnancy can cause compression of the median nerve as it enters the carpal tunnel of the wrist) and De Quervain’s tenosynovitis (similar pathophysiology but this one is the thumb). Others have issues with sciatica (inflammation and/or compression of the sciatic nerve, usually manifested as low back and buttock pain that radiates down the leg and can causes numbness and tingling in your leg/foot) because of baby’s position or because of the adjustments the body makes to accommodate the increased weight and laxity in the pelvis. For the medical folks out there, it’s important to assess all patients with back pain for any neurological sequelae. Nerve root irritation can be assessed by muscle tenderness at various levels: S1 (calf muscles), L5 (extensor hallucis muscles, which affect the toe-walking test), L4 (quadriceps and anterior tibialis, which affect heel-walking with foot dorsiflexion). Also MDs, check for significant muscle weakness, sensory impairment, or deep tendon reflex changes that can suggest radiculopathy.

Where are we going from here?

One of my worries used to be that I would be post-dates and would not go into labor no matter how much activity I did. They tell women who are near their due dates to start walking every day to initiate labor, so my thought was, what do women do to initiate labor when they have already been running during pregnancy? :-\ I thought I'd need to do some crazy LSD's (long-slow-distance runs, not the psychotropic drug for those of you thinking I'm insane) at 39 weeks to get the baby out. But, I’m not as worried about this now, mostly because I’m really not certain how much longer I’ll keep going with this. I feel so much better if I get activity, but it is getting harder and harder to do work activities and household chores these days. In short, I am 8 months pregnant...and I'm a resident. Extra sleep might make me change my thoughts on staying active, but sometimes sleep is just more important now. I know, super annoying!  At any rate, each time I do head out for a run, when I feel too slow or my running clothes don't fit or I wonder if I am totally destroying my stride and picking up bad habits, I just think that it could be my last chance to run before the baby comes...and about how special it is to share the intimacy and stream-of-consciousness thoughts of my running with her...and I let all my anxieties about the stupid stuff from the day and the worries about tomorrow fade. Yes, I am getting a little awkward these days, but, I’m here, my baby is still growing and active, and after admitting ex-28-weekers, I can only say that I’m just so glad she’s still going along for the ride and staying in the incubator for now!

Interesting tid-bits and references:
Ponnapula P, Boberg JS. Lower extremity changes experienced during pregnancy. J Foot Ankle Surg. 2010 Sept-Oct;49(5):452-8.
Riberiro et al. Static and dynamic biomechanical adaptations of the lower limbs and gait pattern changes during pregnancy. Womens Health. 2013 Jan;9(1):99-108.
Thein-Nissenbaum JM et al. Low back and hip pain in a postpartum runner: applying ultrasound imaging and running analysis. J Orthop Sports Phys Ther. 2012 Jul;42(7):615-24.

Next up: Patellofemoral Pain Syndrome!