Maintaining Mobility: Review of Adaptive Products, Braces and



Maintaining Mobility: Review of Adaptive Products, Braces and
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
of the Pregnant and Postpartum Woman
Scope of the Topic Pregnancy and Postpartum
Prevalence of Pain in Pregnancy
 Wide range reported in the literature; likely due to differences in definition and patient
under reporting pain
 Low back pain and pelvic girdle pain (PGP) prevalence during pregnancy
 72%
n=891 (Mogren 2005)
 68.5% n=645 (Wang 2004)
 40%
n=855 (Ostgaard 1991)
 20%
n=4,724 combined studies (Vleeming 2008)
 30-50% report pain severe enough to lose time from job & refrain from social interaction
(Noren 1997, Kristiannson 1996, Ostgaard 1991)
 Of those reporting pain to their physician, only 15-30% report receiving treatment for
complaints (Owens 2002, Stapleton 2002)
 High levels of pain in pregnancy correlates with perceived decreased ability for functional
activities and increased sick days (Cherry 1987)
 Women with pain in one pregnancy at greater risk for back pain postpartum (Ostgaard 1997,
Turgut 1998)
 20% of women experiencing severe pain during pregnancy reported they will avoid future
pregnancy due to fear of LBP (Brynhildsen 1998)
Risk Factors for LBP and PGP During Pregnancy
 High correlation (Vleeming 2008, Wu 2004 Albert 2001)
 History of previous back pain or SIJ pain
 History of previous trauma to pelvis
 Pain in prior pregnancy
 Conflicting evidence
 High work load
 Age
 Non risk factors
 Time since last pregnancy
 Weight
 Smoking
 Use of birth control pills
Patient Knowledge of Risk Factors/Education
 Postpartum women have a deficit of knowledge about effects of childbirth (McLennan 2005)
 Knowledge of the impact of childbirth on the pelvic floor (Dunbar 2011)
Prevalence of Musculoskeletal Dysfunctions Postpartum
 Survey of women who delivered within the past 3 months (Figeurs 2004)
 Only 13% reported receiving any educational information from their healthcare provider
regarding these symptoms
 Postpartum depressive symptoms are 3x more likely in women having back and pelvic pain
than those without (Gutke 2007)
 Self-reported postpartum symptoms (Shytt 2005)
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
Postpartum Self Related health (SRH) reflects general wellbeing and everyday functioning
(Schytt 2007)
 SRH predicts morbidity and use of health services
 Most important contributing factors to SRH at 4-8 weeks after childbirth
o “Physical symptoms”
o “Emotional problems”
 Perineal pain may cause a majority of problems especially for first time mothers
 30% - 43.2% report LBP at 6 months postpartum (Ostgaard 1997, 1992)
Implications for the Lifespan
 37 % of women reporting back pain in pregnancy still reported back pain at 18 months
postpartum (Larsen 1999)
 8.6% suffered pelvic joint pain 2 years postpartum (Albert 2001)
 Women with high pain intensity during pregnancy have a greater risk for back pain
postpartum (Ostgaard 1997, Turgut 1998)
 Link between LBP and SUI (Eliasson 2007)
 N=200 non-pregnant women with LBP
 78% had SUI
Implications for the Clinicians
 Although incidence of PGP and LBP in pregnancy is high, relatively few patients report
symptoms to physicians and few are actively receiving care
 Musculoskeletal conditions limiting function during the pregnancy often continue into the
postpartum period
 Although women commonly report symptoms postpartum related to musculoskeletal
dysfunction and pain, a low percentage of women receive relevant information or education
on these topics
 Women with perinatal back and pelvic pain are more likely to have postpartum depressive
 Symptoms during pregnancy, birth and in the postpartum period can have an effect on the
woman throughout the lifespan
 Physical therapists, as experts of the musculoskeletal system and function, are essential to
provide pain relief and to optimize function during the perinatal period
 Physical therapists work with the healthcare team to coordinate safe, collaborative care for
women during pregnancy, labor and delivery, and postpartum
 Role for physical therapist in exercise
o Exercise prescription for all exercise levels during pregnancy and postpartum
o Instruction of prenatal and postnatal exercise classes
o Discussion regarding disease management through exercise
 Role for physical therapist in labor and delivery
o Positioning strategies to minimize stress of preexisting musculoskeletal conditions
o Education of patient, patient’s support group and other medical professionals
o Postpartum cesarean management and care
 Obstetric PTs have an opportunity to educate patients, public and doctors
 Get involved in physician rounding
 Get involved in community education projects- particularly those in low socioeconomic
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
Be the educator for your patients during pregnancy. What should she expect
postpartum and what is not normal?
Anatomic and Physiologic Changes During Pregnancy and Postpartum
Anatomic - Skeletal Changes
 Sacroiliac Joint (SIJ)
 Pelvic joints and ligaments loosen under the influence of relaxin
 Movements increase and the sacroiliac locking mechanism becomes less effective
permitting greater rotation and allowing alternations in pelvic diameters at childbirth
 Diverts the strain of weight bearing to the ligaments with frequent SIJ strain
 Pubic Symphysis Joint (SIJ)
 Defined as a unique joint consisting of a fibrocartilaginous disc sandwiched between the
articular surfaces of the pubic bones (also referred to as a secondary cartilaginous joint
in modern anatomical reference texts) (Becker 2010)
 The hyaline cartilage is marked by reciprocal crests and valleys connected by
fibrocartilage which makes up the interpubic disc
 Innervated by the branches of the iliohypogastric, ilioinguinal and pudendal nerves
 Softening of the pubic symphysis and SIJ joint are caused by production of relaxin and
other pregnancy hormones (Standring 2008)
 Ligaments (Standring 2008)
 Separation of symphysis (Bjorklund 2000)
o Normal separation: 1 mm – 5 mm
o Average width non-pregnant female: 4.0 mm
o Increase in pregnancy: Additional 0.5 – 7 mm
o Average width in pregnancy without pain: 6.3 mm
o Physiological separation is usually no greater than 10 mm
o Use precautions if more than 7-8 mm separation
o Pregnant women with symphyseal width of greater than 9.5 mm experience pain
o Frank separation of the pubic symphysis is equal to or greater than 10mm (one
centimeter): Assume ligamentous compromise
o Urethra lies close to the pubic symphysis less than 2.5 cm (Standring 2008) as it
passes through the perineal membrane. Pubic irritation can result in blood in the
urine because of this close anatomical relationship
o Average first week post partum separation: Separation is decreased by 2mm
 Rib Cage
 Ribs become more mobile due to hormonal influence of articulations with the spine:
o Subcostal angle widens
o Ribs flare laterally
o Rib cage increases:
 About 2 cm transversely
 10-15 cm in circumference
Diastasis Rectus Abdominis (Boissonnault 2011, 1988)
 Diastasis rectus abdominis (DRA) is a separation of the rectus abdominis muscles due to
stretching of the linea alba and can be noted along at the level of umbilicus or along the
entire abdomen (Stephenson 2000)
 Causes
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
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 Changes in maternal hormones softening connective tissue
 Increased weight in pregnancy
 Increased elongation of the rectus abdominis (Gilleard 1996)
 Painless condition occurring frequently in pregnancy
 Present in 27% of women in the second trimester
 Present in 66% women in third trimester
 Present in 30% women at 8 wks postpartum
 Assessment is done during a supine hook lying curl up with abdominal palpation, measuring
tape, or digital calipers to measure the distance between the contracted recti- (Boxer 1997)
 Considered significant if separation between medial borders of muscle bellies is greater than
2.0 cm (Nobel 1982)
 Significant DRA suggests impaired force closure of the abdominal muscles resulting in
impaired load transfer and instability with vertical loading tasks (Lee 2007)
Ligaments (Standring 2008)
 Broad Ligament
 Round Ligament
Postural Changes in Pregnancy
 Progressive alterations in body shape and weight
 Changes in center of gravity
 Wider base of support
 Effect of relaxin on connective tissue and underlying fascia of breasts and ligament with
increased weight of breasts leads to increased strain on pectoral muscles, increased thoracic
kyphosis and nerve compression of the brachial plexus
 Changes in Balance
 Center of gravity moves forward secondary to enlarging breasts and uterus
 Butler (2006) studied the changes that occur in balance during pregnancy and post partum
 Data suggests there is decreased postural stability in 2nd and 3rd trimester lasting up to
6-8 weeks postpartum
 Increased reliance on visual input during this time
 Kyphotic-lordotic posture in pregnancy (Stephenson 2000)
 Postural Control in Pregnancy (Drife 2009)
 Increased sway in second and third trimesters with static standing, compared to
nonpregnant women
 Increased sway in all trimesters with eyes closed: increased reliance on visual input for
balance in pregnancy
 Change in balance strategy from ankle to hip strategy with reduced base of support
 Exercises with varying visual input and bases of support may be beneficial to address
postural control in pregnancy
 Significant posture changes between 1st and third trimester include:
Increased lumbar lordosis, increased anterior pelvic tilt, and increased posterior head
position (Franklin 1998)
 No significant relationship found between back pain intensity and changes in posture
 Can cause stretch to round ligament contributing to pain and posture changes
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
Observational Postural Findings Associated Low Back Disorders (Non-Pregnant)
Herniated disc
Radiographic instability
Sacroiliac dysfunction
Degenerative disc disease
Spinal stenosis
Facet impingement
Nerve root adhesion
Observational Finding
Flattened back
Excessive lordosis
Flattened back
Hypertrophic supraspinous ligament
Flattened back
Flexed back, usually unilateral
Bad posture, avoids forward flexion
Adapted from Cook C. Orthopedic Manual Therapy: an Evidence-Based Approach. 2007; Table 11.14: 366
Considerations are to be made on how postural changes that occur during pregnancy may
 A woman with an existing (pre-pregnancy) low back disorder
 A woman’s predisposition for low back disorders during pregnancy
Postural Recommendations in Pregnancy
 Optimal Posture
 Neutral pelvis or slight anterior pelvic tilt
 Pubic bone in same plane / aligned with ASIS and xyphoid process
 No excessive gluteus maximus, erector spinae, rhomboid, abdominal oblique muscle
 Avoid asymmetric postures
 Asymmetric laxity of the sacroiliac joints is predictive of pelvic girdle pain (Damen 2001)
Lower Quarter Biomechanics
 Hip, foot, and ankle biomechanics
 Conventional thinking: over pronation can cause hip internal rotation and a drop of the iliac
crest on that side
 Can cause overstretch of the piriformis, sacral rotation
 Stresses medial knee ligaments
 Stresses foot intrinsics
 No relationship between pronation and LE internal rotation (Reishi 1999)
 Hypothesis is that the problem is with the hip abductors – weakness in these muscles
can result in hip IR and stress to the medial knee and foot intrinsics (Powers 2008)
o Strengthening foot intrinsics, posterior tibialis, and gluteus medius and maximus can
o Best exercises are triplanar with emphasis on control of femoral rotation and
 Example: quadruped position – lift leg into ER, abduction, and extension
o Combination of strengthening and motor control
o Consider orthotics
Physiological Changes
 Hormonal Changes (Decherney 2007, Blackburn 2007) and metabolic changes may
predisponse women to muculoskeletal dysfunctions
 Relaxin: Secreted by the corpus luteum during pregnancy
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
No evidence of increased levels of relaxin correlating with pelvic or symphysis pain
during pregnancy (Petersen 1994, Bjorklund 2000)
Relaxin has been shown to limit collagen production and reorganization, while
stimulating increased collagen degradation. (Samuel 2005)
Prevents fibrogenesis, and reduces established scarring
o Main function: prepare for delivery
o Widens symphysis pubis
o Increased mobility of SI synchondroses
Relaxin effects linea alba which can lead to diastasis recti
Concentration values during pregnancy (Petersen 1995)
o Peak value at 12th week
o Declines until 17th week
o Stable at 50% of peak there after
Relaxes ligaments and connective tissue throughout the body, causes increase in joint
Decreases to pre-pregnancy levels 3 days postpartum
Comparing and Contrasting Selected Musculoskeletal Dysfunctions in Pregnancy and Related
Bracing and Adaptive Equipment Recommendations
 Select examples of common musculoskeletal dysfunctions and considerations for choosing
equipment and bracing
 Spine
 Pelvic Girdle
o Pubic Symphysis
 Extremities
o Hand
o Knee
o Feet
 Not all-inclusive list of special populations – more diagnoses covered in-depth in Section on
Women’s Health “Fundamental Topics in Pregnancy and Postpartum” and “Advanced Topics
in Pregnancy and Postpartum” course (
 Consider evidence based examinations and musculoskeletal diagnosis’s
Low Back Pain
 Generally defined as pain between 12th rib and gluteal fold (Vleeming 2008)
 Ruling out Lumbar Spine with examination of lumbar, lumbopelvic or pelvic pain should first
rule out the lumbar spine (Vleeming 2008)
 Regardless of order of tests, which may be performed based on positional needs
 General order of lumbar exam:
 Standing: Posture, gait, symmetry of landmarks, trunk ROM, repeated motions
o Trunk ROM may be limited naturally by pregnant abdomen
 Seated: Slump sit test, reflexes, dermatomes, myotomes
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
Lying: SLR / other neutral tension testing, additional motions / posture testing,
additional strength testing
 Literature Reports Describing Observations, Measures, Examination Testing, and
Classification of Lumbar-Generated (non-PGP) LBP
 Classifying Patients with Pain of Lumbar Origin into Intervention Groups (Hicks 2005, Hayes
 Traditionally, diagnosis of lumbar pain involves identifying a structural fault followed by
interventions aimed to correct the fault
 Difficult due to inability to identify structural fault in most patients with LBP
 Ignores the potential for structural “faults” that may not actually be pathological or
 Alternative method: Classifying patients into subgroups with similar clinical characteristics
to guide diagnosis and intervention
 Intervention-based classification systems are described in the noted literature/texts and
o McKenzie Institute (McKenzie 1998)
o Treatment-Based Classification (Delitto 1995)
o Movement System Impairments (Sahrmann 2002)
Examination for Spinal Nerve Root Involvement (“Disc Derangement”) (Cook 2007)
 Centralization Phenomenon
 Liberally defined as:
o Reduction of radiating or referred pain from the spine
o Pain is resolved or reduces from a distal to proximal region in a controlled
predictable pattern with the application of (Aina 2004):
 Movement
 Mobilization
 Manipulation
 Centralizing behavior is 94% sensitive (Bogduk 1997)
 Thus - if the test is not positive, disc syndrome is likely not present
 52% specific for the presence of disc syndrome
 Thus - If test is negative, it is moderately unlikely that disc syndrome present
 Use of repeated movements
 Useful to determine the irritability of a patient
 Helps to identify the directional preference of their movements
o “Directional preference” reflects the preference of repeated movement in one
direction that will improve pain and the limitation of range
o Movement in the opposite direction will cause signs and symptoms to worsen (Cook
Tests for Nerve Root Irritation (Traditionally, Disc Involvement)
 Active Physiological Flexion (or Repeated Flexion) (Cook 2007)
 Active Extension-Repeated Movements (or Repeated Extension) (Cook 2007)
 Active Side Flexion / “Side Glide” with Repeated Motions (Cook 2007)
Quadrant Facet Provocation Testing (Facet Joint Irritation) (Cook 2007)
Neural Tension Tests
 Three criteria to avoid false positive with neural tension testing:
o Findings must be asymmetrical between symptomatic and normal side
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
Pain produced from exam should be the same as reported symptomatic pain
Movement of a distal or proximal area that engages tension of the nerve root should
increase symptoms
 Straight Leg Raise (SLR) (Brieg 1979, Cook 2007)
 Slump Sit Test (Philip 1989)
 Femoral Nerve Stretch Test (Estridge 1982)
Lumbar Mobility Testing and Scales
 Vertebral Central Posterior Anterior (CPA or “PAs”) (Cook 2007)
 Lumbar Segmental Instability Test (Hicks 2003)
 The Beighton Ligamentous Laxity Scale (Beighton LLS) (Hicks 2003)
Pelvic Girdle Pain
 Generally defined as pain between posterior iliac crests and gluteal fold, particularly in SIJ
region (Vleeming 2008, Kanakaris 2011)
 Pain may radiate to posterior thigh
 Generally arises with pregnancy (between first trimester and first month post-delivery),
trauma, arthritis
 Onset insidious or sudden
 Decreased tolerance/endurance with standing, walking, sitting (feels need to frequently
change position or activity)
 May affect gait: “catching” or “clicking” of hip, slowed velocity, and increased horizontal
pelvic rotation
Differentiation of PGP from LBP
 Through tests and patient history, observations, tests and measures determine diagnosis
 Some other differences have been noted that differentiate PGP from LBP specifically in
postpartum women: (vanWingerden 2008)
Pelvic Girdle Pain
Static stance – pelvic tilts significantly
Limited trunk ROM with maximal forward
bend, with significant limitation at the hip.
During initial AND final forward bend motions,
lumbar motion Increased.
Low Back Pain
No significant tilt in pelvis noted.
Limited trunk ROM with maximal forward
bend, but hip motion not limited.
During initial forward bend motion, lumbar
motion is DEcreased
During final forward bend motion, lumbar
motion INcreased
Classifications of Pelvic Girdle Pain (modified from Albert 2000):
 Pelvic Girdle Syndrome – daily pain all three pelvic joints (SIJs and PS), confirmed with pain
provocation tests
 Symphysioloysis, or Pubic Symphysis Pain – daily pain in PS, confirmed by pain provocation
tests to PS (not an actual lysis of joint)
 One-sided Sacroiliac Syndrome – daily pain one SIJ, confirmed by pain provocation tests to
this SIJ
 Double-sided Sacroiliac Syndrome – daily pain both SIJs, confirmed by pain provocation tests
to both SIJs
 Miscellaneous PGP – daily pain in one or more pelvic joints, but inconsistent findings
between history and tests (could also include rheumatic disease)
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
The Section on Women’s Health is proud to announce the course schedule for 2014.
We hope you will be able to take advantage of the variety of course options and locations throughout the country.
Registration for 2014 educational courses and the 2014 Fall Conference is now open on our website.
For updates on courses and registration openings, please follow the Section’s Twitter and Facebook pages.
Pelvic Physical
Therapy 1
January 17-19, 2014 (Fri-Sun) <<<
Speakers: Lori Mize, PT, DPT, WCS
Carina Siracusa Majzun, PT, DPT
Greenville, SC
March 21-23, 2014 (Fri-Sun) <<<
Speaker: Lori Mize, PT, DPT, WCS
Houston, TX
June 20-22, 2014 (Fri-Sun) <<<
Speakers: Lori Mize, PT, DPT, WCS
MJ Strauhal, PT, BCB-PMD
Baton Rouge, LA
July 11-13, 2014 (Fri-Sun) <<<
Speakers: Lori Mize, PT, DPT, WCS
Barb Settles-Huge, PT
Des Moines, IA
October 10-12, 2014 (Fri-Sun) <<<
Speaker: Carina Siracusa Majzun, PT, DPT
East Lansing, MI
November 14-16, 2014 (Fri-Sun) <<<
Speaker: Barb Settles Huge, PT
Boca Raton, FL
October 2-5, 2014 (Thurs-Sun) <<<
Speaker: Gail Wetzler, PT
Bethlehem, PA
Pelvic Physical
Therapy 2
Pelvic Physical
Therapy 3
February 28-March 2, 2014 (Fri-Sun) <<<
Speaker: MJ Strauhal, PT, BCB-PMD
Portland, OR
June 27-29, 2014 (Fri-Sun) <<<
Speakers: MJ Strahaul, PT, BCIA-PMDB
Carina Siracusa Majzun, PT, DPT
Rochester, NY
September 12-14, 2014 (Fri-Sun) <<<
Speaker: MJ Strahaul, PT, BCIA-PMDB
Portland, OR
April 25-27, 2014 (Fri-Sun) <<<
Speaker: Barb Settles Huge, PT
Madison, WI
August 1-3, 2014 (Fri-Sun) <<<
Speakers: Carina Siracusa Majzun, PT, DPT
Towson, MD
Fundamental Topics
in Pregnancy and
Postpartum Physical
March 28-30, 2014 (Fri-Sun) <<<
Speakers: Suzanne Badillo, PT, WCS
Susan Giglio, PT, RYT
Baton Rouge, LA
May 16-18, 2014 (Fri-Sun) <<<
Speakers: Karen Litos, PT, MPT
Valerie Bobb, PT, MPT, WCS, ATC
East Lansing, MI
July 25-27, 2014 (Fri-Sun) <<<
Speaker: Suzanne Badillo, PT, WCS
Edina, MN
August 22-24, 2014 (Fri-Sun) <<<
Speakers: Susan Giglio, PT, RYT
Karen Litos, PT, MPT
Longmont, CO
(Hybrid Course – details coming soon!)
November 7-9,2014 (Fri-Sun) <<<
Speaker: MJ Strahaul, PT, BCIA-PMDB
Madison, WI
Advanced Topics in
Pregnancy and
Postpartum Physical
February 21-23, 2014 (Fri-Sun) <<<
Speaker: Susan Giglio, PT, RYT
St. Louis, MO
May 4-6, 2014 (note Sun-Tues) <<<
Speakers: Susan Giglio, PT, RYT
Susan Steffes, PT
Baltimore, MD
The Physical Therapist in W
Labor & Delivery: Advanced
Techniques in Labor Support
October 24-26, 2014 (Fri-Sun) <<<
Speaker: Susan Steffes, PT, CD (DONA)
Austin, TX
Check website for new courses throughout the year!
This course is part of the Section on Women's Health Certificate
of Achievement in Pelvic Physical Therapy (CAPP-Pelvic) Program.
This course is part of the Section on Women's Health Certificate of Achievement
in Pregnancy and Postpartum Physical Therapy (CAPP-OB) Program.
For more details on CAPP, go to
For more information on Section on Women's Health sponsored courses go to or contact
the SOWH at [email protected], or 703-610-0224.
American Physical Therapy Association
Testing of the Pelvic Girdle
 Palpation Tests
 Functional Load Transfer Test
 Pain Provocation Tests
Palpation of the Pelvic Girdle Landmarks
 Of note although used historically, palpation of landmarks is NOT useful to determine a
diagnosis for pelvic, lumbar or hip dysfunction.(Albert 2009, McGrath 2006, Carmichael
 Lack of symmetry does not indicate or correlate with pelvic girdle or hip dysfunction or pain
(Lederman 2010, Levangie 1999)
 Leg length measures also demonstrate poor reliability and lack correlation to pain or
dysfunction (Albert 2000, Lederman 2010)
 Palpatory findings only should be used as a contribution to the Gestalt of the total exam
Functional Load Transfer Tests
 Stork Test (Hungerford 2007)
 Active Straight Leg Raise test (ASLR) (Mens 1999, 2001, 2002A)
 Modified technique for ASLR (Cook 2007, Mens 1999)
Pelvic Girdle Pain Provocation Tests
 Gaenslen’s test (Vleeming 2008)
 Posterior Pelvic Pain Provocation (P4) (Ostgaard 1994)
 Thigh Thrust (Laslett 2003)
 SIJ Anterior Distraction: Posterior Compression (Lee 2004)
 SIJ Posterior Distraction: Anterior Compression (Lee 2004)
 Patrick’s FABER Test (Vleeming 2008)
 Long Dorsal Ligament (LDL) Palpation (Vleeming 2002, Lee 2004)
Pubic Symphysis Pain Provocation Tests
 Modified Trendelenburg (Albert 2000)
 Pubic Symphysis Palpation (Albert 2000)
Bracing and Orthoses
Types of braces and orthotics used in pregnancy and postpartum
 SI belts
 Lumbar supports and Binders
 UE splints
Lumbar supports (Carr 2003)
 No adverse effects of a binder on the hemodynamics of the mother or fetus were found
(Beaty 1999)
 Also useful for round ligament pain
 Types of lumbar supports and binders
o Mother to Be
o Stork S’port
o Motherhood
o Prenatal Cradle
o Soft and Form
o Many others on the market
Sacroiliac belts
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
Studies which support the use of SI belts
o Enhanced stability due to decreased movement at the SI joint (Vleeming 1992)
o Application of a pelvic belt significantly decreases mobility of the sacroiliac joints
(Mens 2006)
o Improvement of the load transfer through the pelvis as measured by the ASLR
improved with SI belt (Mens 1999)
o Neither home nor in-clinic exercises had any additional value above giving a
nonelastic sacroiliac belt and information (Nilsson-Wikmar 2005)
 Recommended use of SI belts
o The decrease of mobility at the SIJs is larger with the belt positioned just caudal to
the anterior superior iliac spines than at the level of the pubic symphysis. (Mens
o Apply SI belt in supine position
o Vleeming (1992) suggest that it is most effective if placed just above the trochanter
or “to patient’s comfort”
o Does not need to be tight: if the belt does not reduce symptoms then tightening it
more will probably not help more
o Systematic Review (Vleeming 2008) suggest that pelvic belts may be tested for
symptomatic relief but should not be used as a single treatment; should only be
applied for short periods
 Types of SI belts
o Active SI Belt
o Serola
o Saunders
o Com-pressor
o SI Lock
Postpartum Binders
 Gentle abdominal support after delivery
 Support the belly by slinging the brace under and Velcro
 Especially helpful after a C-Section
 Helps you return to your normal activities sooner
 Types of Binders
o Dale abdominal binder
o Better Binder
o Loving Comfort
 Can be worn during pregnancy with caution not to restrict circulation
Other supports
 Baby Hugger
o All in one panty/support
o Relieves pressure on the pelvic floor and decreased compression on the blood
vessels returning blood from the leg; helps with varicosities
o May also help with relieving pressure on lateral femoral cutaneous nerve
 Meralgia Paresthetica – patient presents with numbness and burning in the
anterolateral thigh without motor involvement (Ritchie 2003)
Review of Evaluation /Intervention Algorithm for Lumbopelvic Pain
Review of Bracing Algorithm
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
Bracing Extremities
Upper Extremities
 Carpal Tunnel Syndrome
 Common complication of pregnancy
 Prevalence as high as 62% of pregnant women (Ablove 2009)
 De Quervain’s Syndrome in postpartum women
 Related to repeated injury to the dominant wrist in flexion and ulnar deviation
(Anderson 2004)
 Wrist splints
 Splinting is a noninvasive method for helping to decrease the uncomfortable symptoms
of carpal tunnel syndrome during pregnancy. (Courts 1995)
o 48 women (82 hands) compared to 26 women with no hand symptoms
o Rated symptoms included: Tingling, numbness, pain, weakness, wakes you up, drops
things, swelling, and stiffness, grip strength and pinch strength
o One week after splinting, there was an average increase of 5.4 pounds in grip
strength and over 1 pound in each type of pinch strength (p < 0.0001).
o Splint group:
 Each of the eight symptoms decreased
 At 1 month postpartum, symptoms had resolved completely for 76% of the
 Weakness had resolved for 76%; strength was improved, but was not normal.
 “Wakes you up” symptom resolved for 93%
 Systematic review (Borg-Stein 2005)
o Night splints are the most recommended therapy for carpal tunnel syndrome
o Designed to maintain neutral wrist extension and thus decrease compression on the
median nerve
o 95% of women with CTS will have resolution of symptoms 2 weeks postpartum
o Nursing may prolong symptoms
o >80% will get relief with thermoplastic night splint
Adaptive Equipment/Bracing Considerations for Select Special Populations
 Select examples of two very different special populations with high risk factors and special
considerations for choosing equipment/bracing
 Obesity
 Spinal Cord Injury
 Not all-inclusive list of special populations – many more covered in-depth in Section on
Women’s Health “Advanced Topics in Pregnancy and Postpartum” course
 Consider individual impairments and risk factors
 Avoid making presumptions on medical diagnosis alone
 May be able recommend similar adaptive equipment or bracing for different special
populations than those covered here who face similar challenges
o Example: Women with Guillain-Barre Syndrome may have paralysis/paresis
impairments similar to women with spinal cord injuries
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
Obesity-Related Impairments in Pregnancy and Postpartum
Overview and Statistics
 Obesity Epidemic (Ogden 2012) (NRC-IOM 2009)
 Fastest growing health problem in the U.S.
 2010 statistics:
o No state has prevalence of obesity less than 20%
o 36 states have prevalence at or above 25%
 12 of these states had prevalence at or above 30%
 Two-thirds of U.S. women child-bearing age are classified as overweight (BMI greater
than/equal to 25 kg/m2)
o Almost one-third of these women are classified as obese (BMI greater than/equal to
30 kg/m2)
Obstetric Considerations With Obesity in Pregnancy/Postpartum (SOWH 2013)
 Cardiovascular: coronary artery disease, gestational hypertension, pre-eclampsia/eclampsia,
pulmonary vascular disease
 Pulmonary: hypoxemia, obstructive sleep apnea, respiratory depression during labor and
 Digestive: incompetent esophageal sphincter function (GERD)
 Metabolic: Gestational Diabetes Mellitus; various coronary, renal and cardiac diseases
 Psychological/Social: Depression, social stigma, less likely to seek/receive healthcare
 Risk factors for the fetus: Preterm birth, birth weight – large/small for gestational age,
multiple neurodevelopmental disorders
Musculoskeletal Problems (Hoffman 2009)
 Obesity leads to higher incidence of osteoarthritis: 31%, compared to 16% non-obese adults
 Implicated in progression of low back pain due to mechanical stress on discs and indirect
effects of atherosclerosis on blood supply to lumbar spine (Kulie 2011)
 Obesity at age 23 increases risk of LBP onset within 10 years (Lake 2011)
 Strongly linked to knee osteoarthritis due to excess load on joint, increased cartilage
turnover, increased collagen type 2 degradation products and increased risk of degenerative
meniscal lesions (Kulie 2011)
 Average BMI in women diagnosed with knee OA is 24% higher than women without OA
 For every 2 unit increase in BMI, risk of knee OA increases 36%
 Obesity linked to increased risk of developing rheumatoid arthritis (Crowson 2012)
 Paired cohort study of medical records for 1626 women (813 with RA; 813 without RA)
from 1985-2007
 Obesity accounted for 52% of increase even after adjustment for other factors
Mobility impairments
 Limited endurance and functional strength for ADLs
 Exercise Guidelines With Obese Pregnancy (Hopkins 2011, Mottola 2009)
 Exercise may result in modest reduction of LGA without significant increase in SGA
o Results in favorable long-term outcomes for infant
 Walking has been shown to be the most popular activity during pregnancy
 In combination with nutritional control can be effective in preventing excessive weight
gain in overweight and obese women (Mottola 2009)
 Brisk walking program may be beneficial in reducing GDM risk in obese women
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
Study comparing obese pregnant women who did not participate in vigorous
exercise but did participate in brisk walking program had 34% reduced incidence of
GDM compared to control group who walked at leisurely pace (Berger 2002)
o Pilot study using a mild walking program (30% of estimated heart-rate reserve) was
successful in improving glucose regulation and reducing insulin requirements in
overweight women with GDM (Davenport 2008)
o Started walking 25 minutes per session three to four times per week, building slowly
by adding 2 minutes per week until 40 minutes was reached
o Only partially successful in preventing excessive GWG (50%)
 Equipment Considerations
 ADL assessment needs: Standard walkers, commodes, and wheelchairs are not
reinforced for excess weight; may need to consider ordering heavy duty durable medical
equipment for home or hospital needs
Size-Friendly Products and Resources (SOWH 2013)
 Baby Carriers and Slings
 Front-Pack Carriers: In general will accommodate ‘mid-size’ parents (up to size 22/24).
Do not fit ‘apple shape’ or women with large breasts well. Examples:
o Baby Bjorn Carriers: Can be used by larger parents. Custom
sizing available
o Kelty Kangaroo Carriers: Size-friendly: Fit up to 59” waist.
o Snuglis: Not size-friendly for all, but may fit smaller plus-size
o Sutemi Pack Baby Carriers: Fit large-busted frame; comes
with waist extender option
o Ergo Carriers: Work well with women with back issues; Easy to
carry larger infants; Comes with waist extender option
o Baby Trekkers: Heavily padded; straps form ‘X’ in back for
improved weight distribution; waist strap fastens by Velcro. Can also be worn as a
backpack with baby facing out.
o Mei Tai Carriers: Versatile from birth through toddler,
front, back or hip carrier.
 Slings: Versatile, easy on back and size forgiving; several brands come in larger sizes.
o The Maya Wrap:
o The Over the Shoulder Baby Holder:
o The Baby Bundler wraparound sling:
o Wraparound Slings:
o Custom slings:
o Kari-Me Baby Carriers:
o New Native Tube Slings:
o Rebozo Sling: Traditional sling of Mexico, 100” x 30”.
 Hip Carriers:
o The Cuddle Carrier: Best for older children; fanny-pack
design that converts into a hip seat with a waist belt converting into a padded
shoulder strap. Compact, double-duty design.
o The Hip Hammock: Available in custom sizes.
 Carrier Product Review Site: The Baby Wearer:
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
Nursing Products
 Maternity Bras and Nursing Pillows
o Breast is Best:
o Double Blessings Nursing Pillow: Nursing pillow for
twins, strap fits around mother with waist measurements up to 54”.
o My Baby’s Nest: Designed to fit larger-breasted women,
waist belt strap fits up to 60” waist.
o My Brest Friend: Manufacturer states it fits waists up to
60” with special extender strap.
o Bosom Baby Plush Line Nursing Pillow: V-Shaped
nursing cushion in plush material, zippered removable pillowcase. (Multi-product
website for new mothers with other size-friendly products)
o Self Expressions: Nursing bras to 46H. (Multi-product
website, baby slings and other breastfeeding-products.)
Maternity Support Belts
 Mom-Ez Maternity Back Support: Contoured adjustable cotton
support belt with full low back support. Fits hips up to 79”
 Reenie Belt: Adjustable sacroiliac-type belt support fits up to
size 2x (46” hip).
 Belly Bra. Combination maternity bra/support belt in sizes up to
 Prenatal Cradle. Abdominal support belt with
shoulder straps. Sizes up to XL (size 24+, 300-350 lbs). Also available in tall sizes for
women over 5’10”.
 Mother-To-Be support belt. Sizes up to XXL (22-26).
 Serola SI Belt – commercially available up to size XL, however can special order larger
sizes directly from company with delivery in four days. Also can order belt extenders.
Miscellaneous Products
 Birthing Ball: Natural fitness 600# Professional Burst Resistant Exercise ball
 Hygiene: Online store with variety of hygiene, travel and medical
 Tips for avoiding skin breakdown:
o Summer N. “Don’t Sweat It. Tips for Surviving Summer.” Radiance Magazine
Summer 1999.
Plus-Size Mom Support Websites and Blogs
 Plus Size Birth:
 The Plus-Size Pregnancy Website:
 The Plus Size Mommy:
 The Well-Rounded Mama:
Note: The Section on Women’s Health does not endorse any of the following websites or products. These websites are
provided as a starting point for therapists and patients seeking more information or sources of size-friendly products.
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
The sites listed are only a sampling of sources available on the Internet. Call companies to confirm ‘size-friendly’
availability before ordering any product.
Spinal Cord Injury (SCI) in Pregnancy and Postpartum
Overview and Statistics
 Prevalence (Cunningham 2005, Smeltzer 2009)
 Approximately 1.4% of U.S. population (1,275,000 people) paralyzed due to SCI
(Christopher and Dana Reeve Foundation 2012)
 Most SCIs (51%) occur in early adulthood during peak reproductive years, between ages
 Males at greatest risk, but growing number of women living with SCI (18%)
 Fertility is not impaired; nearly 14% of women with SCI will have at least one pregnancy
after injury (Jackson 1999)
 Women with SCI can carry a child safely to term and many can deliver naturally
depending on medical status and physical limitations
 Causes of SCI (n = 1,275,000) (Christopher and Dana Reeve Foundation 2012)
 Work-related accident: 28% (7% as result of injury occurring while in military)
 MVA: 24%
 Sporting/recreation accident: 16%
 Fall: 9%
 Victim of Violence: 4%
 Birth Defect: 3%
 Natural Disaster: 1%
 Other: 6%
 Types of SCI – American Spinal Injury Association (ASIA) Impairment Scale (ASIA 2011)
 A = Complete:
o Transection of the spinal cord, profound disruption of motor or sensory innervation
below level of injury
o No sacral sparing
 B = Incomplete
o Partial damage to the spinal cord
o Sensory but not motor function preserved below the level of the lesion
o Includes sacral segments S4-S5
 C = Incomplete
o Motor function preserved below neurological level of lesion
o More than half key muscles below neurological level of lesion have muscle grade
less than 3
 D = Incomplete
o Motor function preserved below neurological level of lesion
o At least 50% key muscles below lesion have muscle grade of 3 or more
 E = Normal, motor and sensory function are normal
 Incomplete lesions are more common
 May be ambulatory or use wheelchair; degree of impairment related to severity and
location of injury to spinal cord
 Incomplete SCI and related impairments (SoWH 2013)
 Complete SCI and related impairments (SoWH 2013)
Obstetric Considerations During Pregnancy and Postpartum with SCI
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
 Urinary tract infections
 Anemia
 Decubitus ulcerations
 Constipation
 Respiratory system effects
 Thrombophlebitis/DVTs
 Spasticity
 Autonomic dysreflexia
Equipment Considerations
 Mobility/gait and transfer training: weight of gravid uterus may make prior level of
independence more difficult
 Monitor signs/symptoms of carpal tunnel syndrome and need for treatment to decrease
impairment with mobilizing wheelchair
 Wheelchair and seating recommendations
 Requires regular monitoring/modification through pregnancy and postpartum to ensure
appropriate seating system as body changes
 Education regarding frequent maintenance of air pressure in seating system and tires
 Pressure relief techniques and recommended frequency of pressure relief to reduce risk
of decubitus ulcers (every 15 min)
 Safety belts or trunk straps for sitting balance
 Joint protection: bracing and orthotic recommendations, taping, instruction in
donning/doffing braces due to hypermobile ligaments or spasticity with pregnancy
Parenting Considerations
 Lactation
 Breastfeeding is encouraged, however women with SCI less likely to breastfeed
 Possibly decreased milk production with injuries above T6 level contributing factor
(Jackson 2004)
 May need referral to lactation consultant for assistance with positioning, especially with
limited mobility in upper extremities
 Can trigger Autonomic Dysreflexia if pain is associated
 Physical or occupational therapy consult for adaptive equipment; techniques for
breastfeeding and infant care
 Adaptive Childcare Equipment Resource Guide (SoWH 2013, handout available online)
Parenting with a Disability
Demographics/Research (Through the Looking Glass 2010:
 In 2000, about 21% of children under age 18 (15 mil) in U.S. lives with at least one parent
with a disability (U.S. Census Bureau, 2004)
 Although research on disabled parents is very scarce, significant progress has been made in
the past 25 years through the work of Through the Looking Glass (TLG) Website:
 Community-based organization supporting the rights and needs of persons with
disabilities living independently
 Provides information, referrals, publications, training, and consultations regarding
parenting with a disability
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
First National Center on Parents with Disabilities, funded by the National Institute of
Disability and Rehabilitation Research (NIDRR)
 Mother-baby interaction and basic infant care (Kirschbaum 1988)
 1985-88: Videotaped mother-baby interactions to explore tasks such as feeding,
dressing, bathing, lifting, diapering
 Mutual adaptation between mother and baby was documented
o Example: Through a series of strategies to cue the baby of the lift (e.g., positioning,
tugging on clothing), the 1-month-old baby of a mother with paraplegia would help
his mom lift him by flexing his legs and head on her lap, remaining still until the
mother completed the lift
o Mothers with hemiplegia report their babies knew to approach them on their
stronger side
o Conclusion: mothers with disabilities can naturally adapt to baby care, and they can
facilitate their baby’s adaptation
 Adaptive equipment and adaptive techniques can help prevent back or repetitive stress
injuries and alleviate depression associated with exacerbations of the disability postpartum
(Tuleja 1999, Kirschner 2010)
 Equipment must be safe for mom and baby, as deemed by a skilled rehabilitation
 Impact of a mother’s disability on the family
 Predictors of problems with parenting for disabled parents did not differ from those of
nondisabled parents, such as history of abuse in the mother’s family (Kirschbaum 2002)
 No significant difference between children of disabled parents and those of able-bodied
parents in regard to self-esteem, gender roles, family functioning, individual adjustment,
and attitudes toward parents. (Mazur 2006, Alexander 2002)
 Parents with intellectual or psychiatric disabilities are especially vulnerable to
discrimination, lack of appropriate services, and loss of their children (Preston 2010)
o 40-60% out of home placement rates for US parents with intellectual disabilities
o In some cases held to higher standard of parenting than non-disabled parents
Challenges for Parents with Disabilities
 National Survey of Parents with Disabilities (Preston 2010,Toms-Barker 1997)
 1,175 parents with disabilities were surveyed on their needs, experiences, and barriers
 Findings:
o Parents with disabilities face social barriers
 87% - lack of accessible transportation
 69% - lack of accessible housing
 50% did not know how to find adaptive equipment
 A majority of respondents felt adaptive equipment would improve their
independence, efficiency, stress, and fatigue
 48% reported difficulty in affording adaptive equipment
Role of the Therapist
 Part of multi-disciplinary team that may include obstetrician, social workers, psychologists,
pediatricians, physiatrists, occupational therapists, and patient’s personal support system
(family, peers, church, etc.)
 Referral to therapy early in pregnancy important – some adaptive equipment can take
time to make/order
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
Now Available!
• Physical Therapist Management of Patients with Chronic Pelvic Pain
• Medical Management and Physical Therapy Management of High-Risk Pregnancy
• EMG Homestudy
• Physical Therapy in Obstetrics
• Physical Therapy for Osteoporosis: Prevention and Management
• Anatomy and Physiology of Intra-abdominal Pressure
For more information, go to
the Section on Women's Health
website at
or call 703-610-0224.
Women’s Health
Section on
American Physical Therapy Association
Assist in identifying and locating commercially available equipment that works for the
specific needs of the patient/client
 Adaptive baby care equipment and clothing resources
 Childproofing devices with accessibility for parent
 Identify safety needs in the home
Training with safe baby care techniques/activities
Caregiver training on how to assist disabled mother effectively
Plan ahead for upcoming developmental changes of baby
Offer guidance on local resources to create a home to promote the child’s well-being
throughout the child’s developmental stages
Adaptive equipment
 Identify individual strengths and barriers for childcare activities.
 Focus on safety, energy conservation, ergonomics, and parent-child comfort
 Work with rehabilitation engineers for safe adaptation of commercial products to fit the
needs of the patient
 Considerations: Crib access, bathtubs, changing tables
 Mobility considerations
o Ambulation safety; Adaptive equipment for w/c, walkers, etc.
o Carrying equipment:
 Questions to ask with front packs, slings, strollers (Rogers 2006)
 How easy is it to get baby in/out of carrier?
 Will carrier work when baby is older?
 How easy is it to put on/off or put baby in/out?
 Possible to use when baby gains weight?
 Are fasteners easy to manipulate?
 How does carrying baby in front of body affect balance when walking?
 How will it affect balance when baby is heavier?
o Stroller
 Commercially sold strollers often too low to transfer baby comfortably
 Questions to consider (Rogers 2006)
 Heavy enough to support your weight without rolling away if you have to
lean forward?
 Lightweight enough to push easily, take in/out of car?
 Does it have a brake to use while putting baby in/out?
 Ease of brake?
 How well does it turn? Uneven surfaces?
 Can you maintain your balance?
 Easy to store?
 Can it be used to carry your packages?
o Other types of carriers
 Baby lifter/carrier
 Newborn carrier (in wheelchair)
 Toddler carrier
Other parenting considerations
 Breastfeeding
o Hands free pump: Medela bra with attached pump
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
o Nursing pillows
o Feeding table on wheelchair
 Dressing baby: snaps can be very difficult – use zippers, Velcro, larger size clothes
 Identify and access available resources and help/support for childcare
 Postpartum doula
 Family, friends
 Community, church
 Adaptive Childcare Equipment Resource Guide (SoWH 2013)
 Can be used for many populations with either permanent disabilities or temporary
Other Parenting Resources (SoWH 2013)
 Adaptive Equipment Guides
 BabeeTenda:
 Detailed product comparison guides for a variety of infant and baby
 Websites for More Information/Resources on Parenting with a Disability
 Through the Looking Glass:
 Yooralla: Parents with a Disability.
 Parents with Disabilities Online:
 Disability, Pregnancy & Parenthood Int.
 Disaboom Network:
 Family Village: A Global Community of Disability-Related Resources:
 National Women’s Health Information Center:
 Disability Resources Monthly (DRM) Web Watcher: Parents with Disabilities
 Rehab Engineering and Construction Resources
 Rehabilitation Institute of Chicago – Rehab Engineering Department
 National Rehabilitation Hospital – Rehab Engineering Service
 Local university engineering programs – Students in need of final projects
 Books
 Vensand K, Rogers J, Tuleja C, DeMoss A. Adaptive Baby Care Equipment: Guidelines,
Prototypes, & Resources. 2000.
 Rogers, J. The Disabled Women’s Guide to Pregnancy and Birth. 2006.
 Organization Websites Specific to Disability
 Arthritis/Connective Tissue
o Arthritis Foundation:
o National Institute of Arthritis and Musculoskeletal and Skin Diseases:
 Epilepsy
o Epilepsy Foundation:
Multiple Sclerosis
o National Multiple Sclerosis Society:
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
o Mums and
Dwarfism/Little People:
o Little People of America:
o Short Adaptive equipment resource center.
Spinal Cord Injury/Paralysis
o Spinal Cord Injury Information Network:
o Christopher & Dana Reeve Foundation:
o Stroke Awareness and Education Toolkit for Healthcare Providers:
Note: Websites listed are not endorsed by the Section on Women’s Health and this list is not a complete list of
available resources. It is provided as a starting point for therapists or patients seeking information about parenting
with a disability
Take Home Message
 A majority of parents with disabilities surveyed reported adaptive equipment would
improve their independence, efficiency, stress, and fatigue (Toms-Barker 1997)
 PTs are in a position to assist patients with permanent disabilities or temporary impairments
with identifying, recommending and locating adaptive equipment/bracing to:
 Promote patient autonomy to the extent possible with childcare
 Improve safety with ADLs and childcare tasks
 Reduce pain during activities
 Improve quality of life and promote parent-child bonding
Scope of the Topic
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Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
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Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
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Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
Women’s Health
Section on
2014 Women’s Health Resource Directory
• A great resource to learn about products for your patients
• Learn about upcoming courses and conferences
• New Directory is updated throughout the year, adding new information for you!
Professional Continuing Education
Exercise Videos/Programs
Orhopedic Products/Orthotics
Patient Education Resources
Maternity Products and Supports
Pelvic Floor Biofeedback & E Stim
Business Planning & Marketing
Health Organizations
Pelvic Floor Therapy Products
For more information about advertising in the Section on Women’s Health Resource Directory
go to
or contact Sarah Haag, PT, DPT, WCS' • (815) 274-2073 • [email protected]
American Physical Therapy Association
_223938/488-1_Final_Report.pdf. Accessed 6/14/2012.
Tuleja C, DeMoss A. Baby care assistive technology. Technology and Disability. 1999; 11:71-8.
Through the Looking Glass. Website: Accessed 6-12-2012.
Maintaining Mobility: Review of Adaptive Products, Braces and Supports for Mobility Needs
Rebecca Stephenson PT, DPT, MS, WCS and Karen Litos PT, MPT
Adapted from OBF ©Section on Women’s Health, American Physical Therapy Association
Appendix E: Evaluation Algorithm for Lumbopelvic Pain
First question to answer: Does this patient belong in my clinic? Red flags, yellow flags may
indicate referral needed. (Refer to Differential Diagnosis module.)
If NO to red flags or yellow flags, then:
Second question: Am I able to classify the patient into an appropriate intervention group (one of
the LBP classifications or PGP diagnosis) based on patient history and examination? (Hicks 2005,
Hayes 2009, Vleeming 2008)
If NO, then referral may still be warranted.
If YES, then proceed.
Red flag indicates referral needed?
Repeated physiologic movements
cause peripheralization or
centralization? (McKenzie 1998)
Further lumbar testing positive?
SLR, slump sit, segmental tests,
dermatomes, reflexes, myotomes
Make referral; follow up as appropriate.
Likely lumbar impingement; complete
lumbar spine mechanical evaluation.
Consider management with directional
preference exercises, mobilization, and
manipulation based on treatment
classification group. (Fitzgerald 2008,
Hicks 2005, Hayes 2009, McKenzie
1998/2006/2007, Delitto 1995,
Sahrmann 2002)
Likely lumbar involvement; address
lumbar spine first (Vleeming 2008). If no
improvement, evaluate pelvic girdle. If no
further improvement or progressive
neurologic change, refer for MRI.
Pelvic girdle examination tests
positive (including FABER with
posterior pelvic pain)?
(Vleeming 2008)
Hip examination tests positive?
(Cook 2007, Callahan 2007,
Kuhlman 2009, Klaue 1991,
Fitzgerald 1995)
Likely PGP. Address pelvic girdle (next
page). If no improvement, pelvic floor
exam (external or rectal) for PFM
dysfunction. If no improvement and
continued anterior pain with FABER,
positive PPPT, or severe pain with WB,
referral to rule out bony pathology
(Fitzgerald 2008, Adams 1997, Borgerding
Address hip; if no improvement, referral
to r/o bony pathology or intraarticular
joint pathology. (Fitzgerald 2008)
Refer back to physician; follow
up as appropriate.
Appendix E: Bracing Algorithm
Clinical Problem
Recommended Bracing
Sacroiliac pain eased with
compression (ASLR test)
Sacroiliac Belt
Lumbar pain from weak
abdominal support
Maternity lumbosacral
support; Abdominal binder
Round ligament Pain
Abdominal binder;
maternity support
Pubic symphysis pain
SI belt worn low &/or
abdominal supports as
listed above. Try either,
pain relief may be patientdependent
Perineal supporter
Compression hose/support
Orthoses, Heel lifts/cups
Wrist splints
Vulvar varicosities
Varicose veins/LE swelling
Foot pain
Carpal tunnel
Serola, Saunders, Compressor, IEM, S-I Lock, SILock Maternity (has
abdominal support) Hip
Motherhood Ultimate
Maternity Belt, Abdominal
Binder, Mother to Be, Baby
Hugger, Prenatal Cradle,
Mom-Ez, Stork S’port,
Better Binder, Soft Form
Maternity Support Belt
Abdominal binders:
Mother to Be, Baby Hugger,
Prenatal Cradle, Mom-Ez,
Stork S’port, Better Binder
Serola, Saunders, Compressor, IEM, S-I Lock, SILock maternity
V2 support, Femme Jock
Jobst, Futuro, Sigvaris,
Gabrialla, etc
Postural correction
Rigid tape; Kinesiology tape; Leukotape, McConnell
Good fitting bra
tape, Kinesiotape,
Spidertech tape, Rock tape
Diastasis rectus abdominis
Postpartum abdominal
3 panel AlphaBrace,
Jeunique, Gabrialla, Belly
Bandit, Tupler Diastasis
Rehab Splint, Better Binder
B9 Biomechanical Strategies in Pregnancy and Postpartum Appendix E
S Steffes, V Bobb
©Section on Women’s Health, American Physical Therapy Association
Appendix B: Adaptive Childcare Equipment Resource Guide for Parents with Disabilities
Possible Solutions
Commercially Available Equipment/Sources
 Practice with
equipment/positioning using
weighted life-­­size baby doll or
baby-­­size sack of potatoes
 Swap positions/change arms if
 Use UE/pillow support under
infant/baby carriers for more
support if needed
 Consider individual parental
capabilities and challenges in
choosing proper equipment – One
size definitely does NOT fit all
 Online equipment consumer
buying guides and comparisons for use by
persons with disabilities covering commercial
baby carriers, high chairs, strollers (pushchairs),
safety gates, bottle warmers and sterilizers
 Seek consults as needed from PT, OT, Social Work,
Lactation Consultant, Rehab Engineers, others
 Look for commercially available equipment that can
be modified as cost-­­effective alternative to custom
 Gradually build up endurance for activities
 Support infants in carriers with bending
 Check straps and buckles regularly
 Make sure all equipment is safe, provides good
 Never leave baby unattended in carrier
 Refer to OBF Course Manual: Biomechanical
Dressing and
changing infant
 Infant clothing with full length
openings, ribbed necks, large arm
 Velcro or magnetic closures
 Slip on booties/shoes
 Use adjustable height continuous
work surface to avoid lifting
 Keep diapers, wipes, etc on lower
accessible shelves
 Reachers/tongs for hard-­­to reach
babycare items
 Mobiles that dangle above
changing surface to capture
toddler’s interest, less resistance
with dressing/diaper changes
Nursing pillows: Boppy, My Brest Friend, many
available options
Lap Tables: Standard w/c trays available through
home medical equipment companies
Slings: Maya Wrap, Baby Bundler, Huggababy,
many available options
 Rock Me Baby Clothes
 Magnetic closure infant wear: Magnificent Baby:
 Limited commercial availability of Velcro clothing
for infants
 Velcro shoes available at Target, Walmart, many
other large department, shoe and
children’s stores
 Disposable diapers and Velcro diaper covers
Changing table/accessories:
 Combo bassinet, changing table, playpen (i.e.
Joovy Home Playard)
 JJ Cole Diaper & Wipes caddy
transfers and
Bean-­­shaped nursing pillow
Lap table for w/c
Front Sling
Alternative positioning
(sidelying, football hold, cradle
 Online resource with
commercial baby carrier comparison chart of
price, ease of use, comfort, etc. Also comparison
chart of age-­­appropriate carriers, product
reviews, instructions for safe use, forums, more.
 Lactation Consultant/OT
 Consider slings with head support; easy fasteners
 Consider pillow or wedge (facing parent) under
front-­­lying sling to keep baby from sliding off lap
 Alternative burping strategies if unable to hold on
shoulder: Apply gentle moving pressure on baby’s
belly in supported sitting position
 Avoid clothing with set-­­in sleeves, buttons and
 When adapting readily available baby clothes, use
soft baby Velcro available at sewing stores to avoid
 Can adapt wheeled serving tables, tea wagons,
sturdy desk or table for changing/dressing/bath
 Make sure changing pads are secured to solid
surface of safely positioned on bed; Use safety
straps – can use Velcro instead of buckle
 Children can eventually be taught to help: Lifting
bottom for diaper changes; climb up changing table
 Consider using level work surfaces while seated
(desk/table top) to avoid bending/lifting
D13 Parenting With a Disability Appendix B
K Litos
©Section on Women’s Health, American Physical Therapy Association
Appendix B: Adaptive Childcare Equipment Resource Guide for Parents with Disabilities
Bathing infant
Lifting infant in/
out of bed
Feeding infant
Possible Solutions
Commercially Available Equipment/Sources
 Bath inserts and supports that fit
in/over standard tub
 Freestanding baby bath tubs that
can be placed on low table
 Infant bathtubs that fit in sink
 Hand held shower/sink sprayer
 Hand grips that suction to edge of
 Baby visor to keep soap/water out
of eyes
 Cribs with castors allow easy
relocation next to parent’s bed
 For w/c users, need room below
crib for w/c footrests
 Cribs with swinging side or end rail
 Portable cribs with bassinet
attachments for easy reaching
 Easy-­­to use Velcro harness for
securing infant/toddler in high
 Wheeled highchairs with
adjustable trays that lift up, over
the back, or out of the way instead
of requiring removal
 Clean up: plastic sheet or
newspaper under high chair; bibs
with elastic or ribbed neck
 Foam changing pads with sides and washable
covers (i.e. LA Baby 4-­­side changing pad); be
careful about overall height of table + pad
Toddlers: climb-­­up changing table with pull-­­out
steps (Torelli/Durrett)
 First Year’s Infant to Toddler Tub with Sling – fits
single to double sinks; mesh sling & foam pads;
upright backrest
 Primo Baby Bath – unique anatomical shape
keeps baby in place; won’t slip under water
 Puj Tub – soft foldable bath tub that fits any
standard sink
 Lil Rinser Bath Visor – easy to apply, has handle
to remove
 Arm’s Reach Mini Co-­­Sleeper Bassinet
 Chico Lullaby LX Playard
 Babee Tenda Safety Convertible Crib – siderail
for w/c accessibility
 for reviews of commercially
available high chairs and bottle warmers/sterilizers
 Graco DuoDiner Convertible High Chair – multiple
positions; 5-­­way tray; compact
 Oversized Vinyl Splat Mat
 miSwivel Adjustable Feeding Chair for Babies – 3-­­in-­­1
swivel chair converts from reclining infant seat to high
 Babee Tenda Feeding table-­­ large tray; wheeled;
 Inflatable bath inserts are option to avoid lifting,
carrying and/or emptying a heavy plastic baby tub
full of water – Most require babies be able to sit
 Consider using table or desk for seated height
bathing surface to avoid need for bending/lifting
 Crib/cot height can be lowered by cutting legs;
raised by adding bed blocks or castors
 Some cribs have foot-­­operated mechanism that
can be reached with one hand from seated
position in w/c
 Consider using pram for first few months instead
of crib for easy portability
 Consider height, weight, stability, and
manageability in choosing high chair
 Baby chair seats that attach to tables may be too
heavy for parents to maneuver
 General tips for positioning/seating: nonslip
surfaces; lap trays; equipment mounts, blocks for
chair feet; alternatives to high chairs include
cushions/positioning pillows, bolsters, rolled
towel, sand or bean bag
D13 Parenting With a Disability Appendix B
K Litos
©Section on Women’s Health, American Physical Therapy Association
Appendix B: Adaptive Childcare Equipment Resource Guide for Parents with Disabilities
Carrying and
Toddler Mobility
and Playtime
Possible Solutions
Commercially Available Equipment/Sources
 Use of prams/carriers/strollers
 Use of harness to strap baby
securely to parent’s body while in
 Castors on base of playpen to
enable relocation w/o lifting child
 Playpens with solid floors to
prevent toddlers from moving
them; gates with manageable
latches to prevent need for lifting
 Commercial ‘play yards’
 Harnesses with manageable
fasteners/Velcro straps to secure
child in high chair, stroller, swing,
parent’s lap
 Safety gates
 Long-­­handled reachers for picking
up toys
 Easy access toy boxes on castors
that children can assist putting
toys back into when finished
 Gates at front and back doors,
possibly one into kitchen
 Teach verbal cues and behavior
modification to avoid dangerous
areas in the home (stove, outlets,
 Intercom systems
 for reviews of
commercially available strollers and carriers
ge=bwposchart for comparison chart of
commercially available baby carriers
 Baby B’Air – lap harness
 Keep equipment at waist or w/c height to minimize
need to bend and lift
 W/C adaptive baby seats are not available
commercially – refer to Appendix A: Website
Resources for customizing adaptive equipment
 for reviews of
commercially available safety gates, high chairs,
 Friendly Toys Little Playzone – portable, different
 Section off ‘safe area’ in house where child can
 Some parents leave harness on child all the time to
use to lift from floor, playpen and crib; others
leave various harnesses strapped to different
 Harness leaves parent’s arms free
 Harnesses can be lengthened to allow child to walk
beside parent in w/c
If parent is too fatigued to play, consider
playgroups, more sedentary play activities
(reading, puzzles), family support, alternatives (I
am very tired right now, but will play with you
tonight for extra special long time)
 Energy conservation with tasks: schedule activities
for efficiency with location; fewer steps
 Countertops lowered to w/c height are also more
accessible to toddlers
 Babyproof home as any parent should: electric
outlets, stairs, cupboards, medicines, etc
 Many safety gates available on the market – Look
for ease of opening/latching, width (wide enough
for w/c, likely side-­­opening), sturdiness; type of
opening (side, 1-­­way, 2-­­way, front)
 Practice routes/methods of transporting child
safely out of house in case of emergency
 for reviews of
commercially available safety gates
 Baby Monitors – many styles commercially
available on market; some audio only, some
audio and visual monitors
 Baby/toddler shoes with squeakers that alert
parent when child is moving
D13 Parenting With a Disability Appendix B
K Litos
©Section on Women’s Health, American Physical Therapy Association
Appendix B: Adaptive Childcare Equipment Resource Guide for Parents with Disabilities
Parents with
Memory or
Possible Solutions
Commercially Available Equipment/Sources
 Memory assistive device for
parents with cognitive deficits to
prompt for basic details of infant
 Itzbeen Baby Care Timer – 4 buttons to track
baby changing, feeding, napping, waking, etc.
Has extra button that can be customized.
Note: The Section on Women’s Health does not endorse any of the products or websites listed above.
AbleData. Website: Accessed 7/1/2012.
Banney A. Multiple sclerosis and parenting. Multiple Sclerosis Society of Australia. 1996. Website:­­
beingaparent.asp. Accessed 7/1/2012.
Callow C, Tuleja C. Avenue to independence. Disability, Pregnancy & Parenthood international. Autumn 2005 (51). Website: Accessed 7/1/2012.
Disabled Living Foundation. Disability, pregnancy & parenthood. Jan 2010. Website: Accessed 7/1/2012.
Guthrie M. Bringing up baby: products for parents with disabilities. Team Rehab Report. June 1997; 19: 17-­­19.
D13 Parenting With a Disability Appendix B
K Litos
©Section on Women’s Health, American Physical Therapy Association
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