Soft-Tissue Strategies for New Mothers
By Whitney Lowe
This article is from the May/June 2013 issue of Massage Bodywork.
Looking for a great Mother's Day gift for a new mom? How about a massage? It may sound like some kind of advertisement, but there is no joking around with the serious level of musculoskeletal pain new moms endure. Having a child is a joyful time for many mothers, but it can be complicated by significant pain complaints.
Sure, some of this pain will be mitigated by the high level of "love" chemicals coursing through a new mom's veins (opiate-like chemicals the brain releases when triggered by a new love, i.e., the baby), but this effect gradually decreases. Here are some of the common musculoskeletal pain complaints that new moms have, and a discussion about the very important role massage can play in bringing relief.
Pregnancy creates psychological changes
The hormone relaxin is released during pregnancy in order to increase elasticity of the ligaments and allow the pelvis to expand for the baby's delivery; it can take several months for relaxin levels to return to normal after the birth. During this time, moms can be at greater risk for back and sacroiliac pain due to excess ligamentous laxity. Stability issues at other joints may also cause similar pain or biomechanical dysfunction.
While some pain will be reduced after the birth, as the load of the baby is no longer there, any pain complaints as a result of ligament and tendon changes, or postural distortions developed during the pregnancy, are likely to continue. If the mother was not in good condition in the first place or already had postural-related pain, then pregnancy will likely have exacerbated these issues.
As the baby grows during pregnancy, the mother's center of gravity is altered, and her low-back muscles and ligaments must adapt to these changes. Inevitably, postural adaptations are made, which, on their own, add pain and discomfort. The pre-birth physiological changes, along with postural adaptations made to accommodate pregnancy, can lead to ongoing pain and discomfort after the child's birth.
The body is particularly adaptive and able to restore much of its previous health after the baby is born, but new moms usually wind up exacerbating their pain with new, problematic activities. While it would be great if there were ergonomic solutions to all of the following, often there are not--but there are functional changes that can help. These behavioral adaptations, along with massage, can provide new moms some greatly earned relief.
Forward-Head and Upper-Back Posture
Lack of rest is a significant factor contributing to postural disorders. To rest overloaded tissues, there must be breaks from problematic postures. In work-related settings, the person has at least some respite from cumulative stress when they go home at the end of their workday. However, caring for a baby is a 24-7 job, particularly during the first few weeks.
Multiple activities, including comforting, feeding, or holding the infant while he or she sleeps, require mothers to lean over their child, stressing the upper-back region. This posture is often held for a long period of time, leading to cumulative tissue overload.
Once the upper back comes forward of the line of gravity, more effort must be expended by the upper thoracic extensor muscles to hold the torso and head against the pull of gravity (Image 1). In addition, when the head is thrust forward (i.e., forward-head posture), the load on the posterior cervical muscles is increased. It is estimated that for every inch your head is forward of the center line of gravity, an additional 10 pounds of effort must be offset by the posterior cervical muscles.
Chronic muscular tightness and myofascial trigger points are the most common dysfunctional problems resulting from this position, but an under-emphasized danger of these long periods of biomechanical distortion is that they produce dysfunctional neuromuscular patterns. Constant reinforcement of these bad postural patterns can have long-term detrimental effects on posture and proper tissue health.
Treatment should focus on reducing tension in the pectoralis major and other anterior chest muscles. It is often these chronically shortened muscles that perpetuate the dysfunctional patterns. Deep stripping techniques and static compression methods are particularly advantageous. Of course, usually the greatest discomfort is in the upper-back muscles, which have become over-lengthened and fatigued. These muscles will get relief from the same techniques.
Massage will feel good, but soft-tissue treatment alone is frequently not enough for lasting relief. To combat dysfunctional postural patterns, there must be neuromuscular reeducation. It is highly important for moms to address these postural challenges by consciously working to reinforce correct postural alignment and engaging in home care, such as stretching.
Awkward Lifting Positions
A challenge facing new moms is adapting to the increased lifting activities. Picking up the baby starts in the morning and continues after every feeding time, nap, playtime, task, trip, etc. Just this change alone is a huge new physical demand the body is generally unprepared for. The baby will be gaining weight rapidly as well, and that means mom's lifting demands continually increase. The low-back muscles often end up doing a disproportional amount of this lifting work.
It is common knowledge that it is better to bend with the knees when lifting. However, many times moms are bending over a car seat, crib, or are in a situation where it just isn't practical to bend with the knees to lift. In addition, lifting feels like more effort if you have to fully bend down with the legs and lift the body each time as well. Consequently, there is a great deal of bending at the waist and lifting with the low back. This movement puts significant stress on the lumbar muscles, and is a common contributor to low-back pain.
The average multitasking mom also winds up engaging in a lot of quirky maneuvers in an attempt to hold her child and get other things done at the same time. The result is awkward positioning involving side bending and rotation in the lumbar region, which is a notoriously challenging position that can lead to lumbar-tissue overload. In many cases, a seemingly small and insignificant movement can cause serious pain simply because it's the last straw of biomechanical overload for the body.
Carrying the infant in a car seat creates another physical demand on the already fatigued mom. The seat is usually carried on one side instead of with both arms, which means the opposite-side lumbar muscles are taking the primary responsibility for offsetting that load. The car seat's shape puts the baby's weight farther away from the mother's center of gravity as well. As with forward-head posture, the farther the load is from the central axis, the greater the load the muscles must offset. A weight that doesn't seem very heavy can seriously overwhelm soft-tissue structures simply by being lifted farther away from the body's center of gravity (Image 2, page 103).
Muscles such as the quadratus lumborum, multifidus, and erector spinae group carry a primary burden for lifting power in the lumbar region. These compromised positions put these muscles at a mechanical disadvantage, leading to chronic tightness from overload, and sometimes cause strain. Bringing the baby's weight in close to the body, as is done when wearing a front baby carrier, alters and reduces the load on these muscles.
Carrying a car seat also puts excess stress on the tissues in the shoulders and upper extremities. These stresses are magnified when the seat is not lifted close to the body, and can overwhelm muscles that are not that strong, but that still play a major lifting-action role in the upper extremity, specifically the rotator-cuff muscles. For example, lifting objects away from the body's center of gravity can put a much greater load on the supraspinatus muscle, a moderately small rotator-cuff muscle that maintains stability during shoulder movements. There is a poor blood supply to the supraspinatus tendon, and the musculotendinous junction is a common site of strain injury as a result. Overloading the muscle-tendon structures can lead to chronic problems like tendinosis, but could also be a primary cause of rotator-cuff strain.
Treatment approaches should be highly specific. A relatively superficial massage may feel good but not get at the real root of the dysfunction in the deep paraspinal muscles (Image 3). The quadratus lumborum is another deep, low-back muscle that requires highly specific treatment. However, make sure general and more superficial techniques are performed first to make the deep work more effective. The shoulder and upper-extremity regions should also be treated with this same protocol of general and superficial work first, followed by deep, specific work on those muscles most exposed to overuse, such as the deltoids, rhomboids, supraspinatus, and upper trapezius.
Remember that the new mom's joints in the lumbopelvic region may still be more mobile than normal. Advise the client to move slowly after the massage and encourage her to be particularly cautious in how she moves for the remainder of the day as the body readjusts to a different level of muscle tonus.
Off-Balance Lumbopelvic Stress
Watch any mother carrying an infant and it is easy to identify one of the chief biomechanical challenges that leads to lumbopelvic pain in mothers. Holding a child in one arm and hiking the hip on that same side causes a lateral tilt of the pelvis to the opposite side. For example, if the child is held on the right hip, that would be a left lateral pelvic tilt. (Lateral pelvic tilt is named for the low side of the pelvis because that's the side to which the pelvis is tilting.)
Substantial challenges and detrimental effects develop from this postural distortion. Prolonged lateral lumbar flexion with weight bearing can cause irritation of the facet joints on the concave side of the lumbar curvature. The altered compressive load on intervertebral disks can also cause eventual disk degeneration. In addition, this altered pelvic position can adversely affect mechanics and cause pain in the sacroiliac joint.
The pain symptoms from these complaints can be similar and sometimes difficult to discriminate. For example, symptoms of sacroiliac-joint dysfunction can often mimic radiating neurological pain down the lower extremity caused by lumbar nerve root compression. As closely as possible, identify the primary source of pain and discomfort so appropriate treatment can be used.
A primary result of lateral pelvic tilt is tightness in the quadratus lumborum on the side of the hiked hip. It can be challenging to work the quadratus lumborum deeply enough to achieve the needed reduction in tightness in this muscle. A side-lying, active-engagement method is therefore a great way to get appropriate pressure on this muscle and encourage tissue lengthening.
This technique is performed with the client in a side-lying position and angled on the treatment table so that the uppermost leg can be dropped off the back edge of the table (Image 4). Bring the client's leg into full abduction and ask her to hold the position. You will apply pressure with a small contact surface (fingers, thumbs, or a tool) to the lateral aspect of the quadratus lumborum. The client will slowly lower her leg as you perform a static compression or deep stripping technique along the length of the quadratus lumborum. At the end of the technique, the client's leg will be lowered off the back edge of the table. The quadratus is engaged in an eccentric muscle contraction during this motion, which increases the muscle's density and magnifies the pressure applied during the technique.
Postural alterations or dysfunctional biomechanics from a lateral pelvic tilt can cause altered tension patterns in fascial connections from the lumbar region through the posterior lower extremity. Achieving postural and biomechanical balance in this area is most effectively achieved if attention is also given to the gluteal muscles, hamstring muscles, and myofascial and ligamentous connections through the lumbopelvic region.
The new mom can do much to reduce the pain and stresses on her body throughout the day by making some simple changes. A nursing pillow (Boppy) or other pillow brings the baby closer to the chest for feeding, comforting, or napping. When feeding, postures that fully rest the upper back are better, like lying down or sitting in a comfortable chair and putting a pillow behind the head. A front backpack-type carrier is better than a car seat for carrying the child.
New moms should be conscientious about following the usual rules about bending and lifting: lift with the legs and not the low back, which means squatting to pick the child up as much as possible, and avoid odd, twisting positions. The baby should be brought close to the body before lifting (which means dropping the crib side down or removing the tray from the high chair).
A concerted effort to be conscious of posture is very important. The new mom should learn to be aware of how she is bending, holding the child, standing, etc. in order for new and healthy patterns to develop. Finally, that new mom needs a massage. There is abundant research showing the benefits of massage in reducing stress, enhancing the immune system (for her and the breastfeeding baby), and improving quality of life. And, quite frankly, I can think of no better gift for Mother's Day.
Whitney Lowe is the author of Orthopedic Assessment in Massage Therapy (Daviau-Scott, 2006) and Orthopedic Massage: Theory and Technique (Mosby, 2009). He teaches advanced clinical massage in seminars, online courses, books, and DVDs. Contact him at www.omeri.com.