Normal and Abnormal Puerperium & Postnatal Physical Therapy Care

Physical Therapy for Women's Health - 4th Year Students SVU

4. -Puerperiumis defined as the time from the deliveryof the
placentathrough the first few weeksafter the delivery. This
period is usually considered to be 6weeksin duration.
-By 6 weeksafter delivery, mostof the body tissue changes
of pregnancy, labor, and delivery, especiallythe pelvic organs
revert backapproximately to the prepregnant state both
anatomicallyand physiologically.
-Similar changes occur following abortion buttakes a shorter
period for the involutionto complete.
-Fourth trimester is the timefrom deliveryuntil complete physiological involutionand
psychological adjustment.

5. Uterine involution:
Is the processby which the postpartum uterus, weighing about
1kg, returnsto its pre pregnancy state of 50-100g.
1-Immediately after delivery: The uterine fundus is palpable
at or nearthe level of the maternal umbilicus. The measurement
should betaken after emptying the bladder.
2-2 weeks after birth: the uterusbecomes a pelvic organ in the
true pelvis.
3-By 6 weeks:itis usually normal size.
-Lower uterine segment: Immediatelyfollowing delivery, the lower segmentbecomes a
thin, flabbyand collapsedstructure. It takes a few weeks to revert back to the normal
shapeand size of the isthmus.

6. Endometrium:
-Following delivery, the major part of the deciduais cast off with the expulsionof the
placentaand the membranes, moreat the placental site. The superficial part containing the
degenerated decidua, blood cells and bits offetal membranes becomes necroticand is cast off
in the lochia.
-Regenerationstarts by 7th day. It occurs from the epithelium of the uterine glands and
stromal cells. Regenerationof the epithelium is completed by 10th dayand the entire
endometrium is restored by the day 16, except at placental sitewhere it takes about 6 weeks.
Placenta bed:
-The placental sitecontracts rapidly presenting a raised surface which measures
about 7.5 cm and remains elevatedeven at 6 weekswhen it measures about 1.5 cm.

7. Myometrium:
-There is marked hypertrophyand hyperplasiaof muscle fibers
during pregnancyand the individual muscle fiber enlarges to the
extent of 10 times in lengthand 5 times in breadth.
-During puerperium, the number of muscle fibers is not decreased,
but there is substantial reduction of the myometrial cell size.
Withdrawalof the steroid hormones, estrogenand progesterone, may
lead to increasein the activityof the uterine collagenaseand releaseof proteolytic enzymes.
-The connective tissues also undergo the same type of degeneration.
The cervix:
-Itinvolutesalong with the uterine body butitcontracts slowly, so
that by 2 to 3 weeks, the internal os is closed, while the external os
can remain open permanently, giving a characteristic appearance to the parous cervix.

8. The vagina:
-TheVaginagradually diminishesin size.
-In the 1st few days, the stretched vaginais smooth & edematous.
-By the 3rd week,vaginal rugae begin to reappearbutneverto the same
degree as in prepregnant state.
Broad ligaments and round ligaments:
-They require considerable time to recoverfrom the stretchingand laxation.
Pelvic floor and pelvic fascia:
-Take a long time may last to6 monthsto involutefrom the stretching
effect during parturition.

9. Lochia:
-It Is the blood-staineduterine discharge that is consists of blood& necrotic decidua;
While persistenceof red lochiameans subinvolution, offensive lochiameans infection.
Types of lochia:
1. Lochia rubra: for the first 4 days, lochiais redin
color. It contains bloodas well as decidual debris.
2. Lochia serosa: from 5th to 9th day, lochiabecomes
palein color. It contains still some red cells, but
predominantly leucocytesand necrotic decidua.
3. Lochia Alba: after the 10th day, the lochiachanges to yellowish
whitecolor. It consists now principally of serous fluid and leucocytes.

10. Ovaries:
-The resumptionof normal function by the ovariesis highly variable and is greatly
influencedby breastfeedingthe infant. The womanwho breastfeedsher infant has a longer
periodof amenorrheaand anovulationthan the mother who chooses to use formula.
-The onset of the first menstrual period following deliveryis very variable and depends on
lactation. If woman does not breastfeedher baby, ovulationmay occur as early as 4 weeks
postpartum while menstruationreturns by 12th week following delivery in 80% of cases. The
meantimefor onset of first menstruation is 6 –9 weeks.
-Lactation provides a natural method of contraceptionwhoever, in women who is
fully lactating, ovulationand menstruationmay occur up to 6 -12 months.
-The physiological basis of anovulationand amenorrheais due to elevated levels of prolactin
andoxytocin in response tobaby’s suckling.

12. Breast tissue changes:
-Although lactationstarts following delivery, the
preparationfor effective lactation starts during pregnancy.
-Prolactinand Oxytocininitiate milk secretion from
mammary glands previously primed by estrogenand
progesterone.
-For the first 2 days there is secretion of colostrumwhich
a deep yellow serous fluid richin protein,Lactoferrin
and immunoglobulinwhile lowin its fatand
carbohydrates content.
-Proper milk secretion commences at the 3
rd
day and
it may be associated with breast engorgement.

13. COMPOSITION OF THE COLOSTRUM:
-It is deep yellow serous fluid, alkalinein reaction. It has got a higher specific gravity; a
highprotein, vitamin A, sodium and chloridecontent buthas got lowcarbohydrate, fat
and potassium.
-Colostrumand milkcontains immunologic components such as immunoglobulins
(IgA,IgG,IgM), complements, macrophages, lymphocytes, lactoferrinand other enzymes.

14. Abdominal wall:
-The abdominal wall remains softand poorly toned for many weeks.
The return to a pre pregnant state depends greatly on maternal exercise.
Physiologic changes:
-General Changes:
*Temperature→normalbut,
-A reactionary risemay occur after difficult labor. It does not exceed 38°Cand
drops within 24 hours.
-A slight risemay occur at the 3rd day due to engorgementof the breast tissue.
*Pulse→normalbutmay riseif there is hemorrhageor infection.
*After pains →Painful uterine contractions occur in early puerperium
increasing withsuckling due to oxytocinrelease.

15. Urine Changes:
*Diuresisby the 2nd -4th day, as normal pregnancy is associated with an increase in
extracellular water and puerperal diuresis is a reversalof this process.
*Retention of urine may occur due to:
-Atonyof the bladder. -Laxityof the abdomen.
-Recumbency. -Reflex inhibition if the perineumis sutured.
-Compressionof the urethraby vaginal edema.
So, there is an increased incidence of urinary tract infection.
Bowel Changes:
*Tendency to constipationdue to;
-Atonyof the intestine. -Laxityof abdomenand perineum.
-Anorexia. -Lossof fluids.

16. Loss of weight:
May be due to:
*Evacuationof the uterine contents (5–6 kg).
*More fluid loss in urineand sweat(2 kg).
Blood Changes:
*Immediately following delivery, there is slight decrease of blood
volume due to blood loss and dehydration.
*Increased coagulability of the blood continues during the first two
weeks despite significant decrease in several coagulation factors.
*Fibrinogenlevel remains highup to the 2nd week of puerperium
which increasesthe riskfor thrombosis.
*Hemoglobin concentrationtends to fallin the first 2-3 days.

17. Endocrinal changes:
*Sharp decrease in both estrogenand progesteronewith risein prolactinis the main
initiativefor lactation.
*Baby’s Suckling induced signals stimulateoxytocinrelease which is a milk letting factor.
*There is slight increase in Growth hormonelevel also, cortisoland thyroxineand they
play role in lactation.
*ProlactininhibitGNRHwhich result in lactational amenorrhea.
Psychological changes:
*Postpartum depression(mild degree) is common.

18. Postpartum care
*The postpartum care (PPC) is an extensionof both antenatal care (ANC)
Provided during pregnancy and intrapartum care (IPC) provided during
delivery.
1-General health care: as physicaland mental relaxation & reassurance.
2-Observation:for fever, bleedingand lochia.
3-Balanced diet: Providing at least 2500 kcal and diet rich in fibers.
4-Breast feeding: encourage breast feeding every 2-3 hoursand encourage
the mother to take additional amounts of water& fresh juices.

19. 6-Perineal care:regular cleaningwith antiseptic solutions to prevent Genital tract infections
andPelvic floor exercise is started in the 3rd day ifthere is noperineal wound.
7-Care of episiotomy: Regular cleaning with antiseptic solution every 4-6 hours with the use
of LLLTto assist in healingand provide bactericidal effect for the incision.
8-Bowel care: avoidconstipationby drinking sufficient amounts of water, eating food rich in
fibersand walking.
9-Bladder care: frequent emptyingof bladderuntil it regains its pre pregnant tone and capacity.
10-Postpartum visits: the patient is best seen 3-4 weeks after delivery.
5-Abdominal exercises: active exercises should start few days after
laborand onlystaticafter c-sectionuntil 6 weeks after c-section.

20. Abnormal puerperium
*Sub involutionis a medical condition in which afterchildbirth,
theuterusdoes notreturn to its normal size.
*Predisposing factors
-Multiparity
-Bad maternal health
-Caesarean section
-Uterine prolapse
-Overdistension of uterus as in twins and hydramnios
-Retroversion after the uterus becomes pelvic organ
-Uterine fibroid
*Aggravating factors
-Retained products of conception
-Uterine sepsis, endometritis

21. Symptoms:
The condition of Sub involution may be asymptomatic. The predominant symptoms are:
*Abnormallochial dischargeeither excessive or prolonged
*Irregular or at times excessive uterine bleeding
*Backache and irregular cramp like pain is cases of retained products
*rise of temperature in sepsis.
Signs:
*The uterine height is greater than the normal for the particular day ofpuerperium.
*Normal puerperal uterus may be displaced by a full bladder or a loaded rectum.
*It feels boggy and softer upon palpation.
-Semi sitting position encourage drainageof lochiawith 2 hours inprone position (only in
normal labor) dailyto encourage anteversionof the uterus and assistin preventionof RVF.

22. 1-Postpartum hemorrhage (PPH):
*Primary postpartum hemorrhage is loss of blood estimated to be
more than 500 ml followingvaginal deliveryor 1000 ml
followingcaesarean section, from the genital tract, within 24 hours
of delivery (the most common obstetric hemorrhage) and bleeding
may be due to retrained placenta, birth canal trauma, uterine atony or
blood clotting disorders.
*Secondary PPH is defined as abnormal bleeding from the genital
tract, from 24 hoursafter delivery until 6 weeks postpartumand it
is caused by infectionor sub involution of the uterusespecially of the
placental site,Retrained placental tissues as in placenta accreta,increta
and percreta as well as in submucosal fibroid polyp.

23. 2-Postpartum infections:
*Any bacterialinfectionsof the female reproductive tractfollowing
childbirthormiscarriage.
*Signs and symptoms usually include afevergreater than 38°C, chills,
lower abdominal pain, productive cough, delay in uterine involutionand
possibly bad-smellingvaginal discharge.
*It usually occurs after the first 24 hours and within the
first postpartum 3 weeks.
*The most common sites of infection is that of theuterusand
surrounding tissuesknown aspuerperal sepsisor
postpartum endometritis.

24. Causes of puerperal pyrexia:
*Puerperal sepsis
*Urinary tract infection.
*Mastitis or breast abscess.
*Thrombophlebitis (superficial vein thrombosis).
*Respiratory tract infection.
*Other infections.
Puerperal sepsis: is a type of wound infection of the female genital tractthat
occurs during labor or the first postpartum 3 weeks.
-Any case of puerperal pyrexia is considered puerperal
sepsis until proved otherwise.

25. Risk factors for postpartum infections:
*Anemia
*Caesarean section
*Infections of an abdominal incision or anepisiotomy
*Instrumental delivery with genital tract lacerations
*Presence of certain bacteria in the vagina such asgroup B streptococcus
*Premature rupture of membranes
*Multiplevaginal exams
*Manual removal of theplacenta
*Prolonged labor
*Breast engorgement
*Urinary tract infections
*Diabetes mellitus

26. 3-Retrained placenta:
*Retained placenta is generally defined as a placentathat
has notundergoneplacental expulsion(allor partof
theplacentaor membranesremain in theuterus) within
30minutesof the baby’s birth,where the third stage of labor
has been managed actively.
*Retained placenta can be broadly divided into:
-failed separation of the placenta from the uterine lining.
-placenta separatedfrom the uterine lining butretainedwithin
the uterus.
*A retained placenta is commonlya causeof
postpartumhemorrhage, both primaryand secondary.

27. 4-Painful perineum:
*Perineal pain after vaginal delivery affects women’s recovery
from childbirth. Genital tract traumaafter birth is common.
*Both episiotomyand perineal laceration are strongly associated with the presence of
perineal pain during postpartum period. Also, strong
bearing downincreasethe incidence of perineal pain.

29. Physical therapy for painful perineum
-Cryotherapy:
After 20 minutesof application, cryotherapywas effectivein
relieving perineal pain in women in the immediate postpartum
period after vaginal birth with episiotomy(Beleza et al., 2017).
-TENS:
High frequencyTENS is a safeand viable non-pharmacological analgesic resource to
be employed for pain relief post-episiotomy. The routine use of TENS
post-episiotomy is recommended(Pitangui et al., 2012).
-Low Level Laser Therapy:
LLLTcan be used to enhanceepisiotomy wound healing, & to induce analgesic effects if
proper wavelength, energy density and exposure time are selected (Suhaila, 2011).

30. -Ultrasonic Therapy:
*USshow a statistically significant result in reductionof painand
improvement in subjects with persistent superficial dyspareunia after
episiotomy(Farzana et al., 2017).
*Therapeutic ultrasound can be used as a alternative noninvasive
treatmentfor relievingperineal pain and promote healing following
vaginal delivery with episiotomyto aid functional independence during
the postnatal period (Mahishale et al., 2013).
-Scar tissue mobilization:
*Scar tissue mobilization show a statistically significant result in
reductionof painand improvement in subjects with persistent superficial
dyspareunia after episiotomy(Farzana et al., 2017).

31. -Pelvic floor exercises:
*The use of Kegel exercises after episiotomyis associated with less pain, analgesic
consumptionand frequency of analgesic use (Mahmodi and Mobaraki, 2014).
*Practicingpostnatal Kegel exercises had a significant effecton decreasingperineal pain
and accelerating healing of the perineal incision after episiotomy(Farrag et al., 2016).

32. A)Varicose veins:
Many women have varicose veins during pregnancy, butsometimes
this problem may stay after pregnancy. As the damage that veins
may have suffered remains irreversible.
Management:
*Avoid prolonged sitting or standing
*Bandaging
*Burger’s exercises
*Intermittent compression
-Sequential pneumatic compression therapy with the applied parameters was an
effectivemodality for increasing venous blood flow, reducing pain, and improving
qualityof women lifewith varicose veins (Yamany and Hamdy, 2016).
5-Circulatory problems:

33. B) Hemorrhoids (Piles):
*Hemorrhoidsare painful swelling of veinsin the rectum.
After delivery -especially after a vaginal deliveryand
Symptoms include pain, rectal itching, bleedingafter
defecationor a swollen areaaround the anus.
*Many womenexperience them for the first-timeduring pregnancy
or the postpartum period for several reasons, including a rush of hormones,
internal pressureand constipation.
Management:
*Avoid constipation
*Ice gel packs application 10 min.
*Low Level Laser Therapy (LLLT)
* Pelvic floor exercises

34. 6-After pains:
*Women may experience cramping pain and discomfortfollowing the
childbirth as the uterus contracts and returnsto its pre-pregnancy size.
*These after pains are causedby involutionary contractions and usually last
for two to three days after childbirth. They are more evident for women who
are multiparous.
*Breastfeedingstimulates the uterus to contractand increases
the severityof after birth pains.
Management:
*Heat application 15-30min.
*TENS.
*Relaxation training with breathing.

35. 7-Feeding difficulties:
A) Breast engorgement:
Breast engorgement is uncomfortable swellingthat results in
painful, tenderbreast, it is associated with an increase in blood
flow and milk supplyand it occurs in the 3rd day after delivery.
Management:
*Regular feeding every 2-3 hours and8-12 times throughout daily.
*Moist heatapplication for15-30minbeforelactation.
*Coldcompresses for 10 min. to reduce swelling painand vascularityafterfeeding.
*TENS:high frequency 60 HZ, for 30-60min.
*Ultrasonic therapy:Pulsed, 1MHz,0.5W/cm
2
and Duration 10:15 min.
-Ultrasound therapy helps in reductionof painwith non-tender breast which further helps the
post-partummothers to recover better from discomforts of breast engorgement
(Priyanka et al., 2016).

36. B) Mastitis:
-Mastitisis an infectionin the tissue of oneor bothmammary glands
inside the breast tissue.
-It is associated with pain, rednessand axillary lymph nodes are enlarged
usually affects women who are breast-feeding in the 2
nd
week postpartum.
-Also, it has another peak in the 4-5
th
week postpartum.
-It is usually associated cracked nipples, allowing bacteriato enter the breast from nipples.
Management:
*Cold Application for 10 min. to reduceswelling and inflammation.
*Low level laser therapy: LLLTis a painless treatment, which appears to accelerate wound
healingof cracked nipples and ease pain (Buck et al., 2016).LLLTtherapy is beneficialin
decreasing the somatic cell count and improving milk nutritional quality with an
intramammary infection (Wang et al., 2014).
*Bedrest &Continue breastfeeding.

37. C) Blocked ducts:
-Blockedor plugged ducts is a condition where a blockagein a
milk duct results in pooror insufficient drainage of the duct.
-When milk builds up behind the blockage, the concentrationof
pressurein the duct may lead to local discomfort or lump
formation in the breast. It may be called non-infective mastitis.
Management:
*Moist heatapplication for15-30min.
*Continuebreastfeeding.
* Feedingwith the affected side firstly then the unaffected.
*Ultrasonic Therapy: US was a beneficial treatment for women presenting with
blocked ducts and difficulties breastfeeding.100%(continuous) duty cycle, 1 MHz,
2 W/cm
2
, 10 min (Lavigne and Gleberzon, 2012).

38. 8-Diastasis recti:
*Diastasis recti is a fairly commoncondition of pregnancyand
Postpartumin which the right and left halvesof Rectus abdominis
musclespread apart at the body’s midline fascia (stretchedlinea alba)
which is a tendinous, fibrous raphe that runs vertically down the midline
of the abdomen. It extends between the inferior sternum and pubis; Linea
albagenerally lacks blood supplyand innervation. a gapabout 2.7cm
orgreaterbetween the two sides of therectus abdominis muscle is considered positive sign.
*In pregnantorpostpartumwomen, the condition is causedby
The stretchingof the rectus abdominisby the growing
uterus. It is more common inmultiparouswomen.Additional
causes can be attributed to excessive inappropriate abdominal
exercises afterthe first trimesterof pregnancy.

39. Examination for Diastasis Recti:
*Instruct patients to perform a self-testonor
after the third postpartum day for optimal
accuracy. Until 3 days after delivery, the
abdominal musculaturehas inadequate tone for
validtest results.
*Patient position and procedure: Crock lying.
Have the patient slowly raise her head and shouldersoff the floor or plinth, reaching her
hands toward the knees, untilthe spinesof the scapulaeleavethe floor or plinth. Placethe
fingersof one hand horizontallyacross midlineof the abdomenat the umbilicus(Fig. 24.6).
If a separation exists, the fingers will sink into the gapbetween the rectus muscles, or a
visible bulge between the rectus bellies may be appreciated. The number of fingers that can
be placed between the muscle bellies is then documented. Because this conditioncan occur
above, below, or at the level of the umbilicus, testfor it at all three areas.

40. *Rectus diastasis rehabilitation:
1)Kinesio tape
2)Core stability exercises:
-TA breathing
-Side plank
-Side lying leg lift
-Dead bug crunches
-Scissor kicks
-Heel slides

41. Exercises NOTsuitable for Diastasis recti
1) All frontal planks
2) All crunches
3) Push ups
4) Sit ups
5) Twisting movements
6) Quadruped exercises

42. 9-Back pain:
*Back pain is a common symptom during pregnancyand postpartum
period due to multiple factors, including weight gain, changesin
posture, mechanical impact of anesthesia, bad posture during care
of baby, lactation and sleeping positions. In addition, the changing
hormone balance that relaxes the strong ligaments of the pelvis in
preparation for childbirth can affect the back.
*Manyof the common causes of back pain during pregnancy
continue after delivery and women also complain of cervical,
thoracicand lower back dysfunctions.
*After delivery refereed back painalso may be due to involutionary
uterine contractionsor urinary tract infections.

43. Physical Therapy Assessments for Postpartum Back pain
-Completehistory.
-Active then passive physiological movements.
-Passive segmental motion.
-Passive accessory motion.
-Assessment of myotome, dermatome and reflexes.
-Special tests for some cervical disorders-Special tests for some low back disorders
*For Thoracic outlet syndrome (TOS): *For facet joint arthropathy:
-Roos test. -Quadrant test.
*For cervicogenic headache: *For sciatica:
-Flexion rotation test. -Straight leg raising test.
-Piriformis test or active piriformis test.
*For Spondylolisthesis:
-Test of anterior lumbar spine stability.
-passive lumbar extension test.

44. Physical Therapy Treatments for
Postpartum Back pain
-Hot packs & Kinesio tape
-Ultrasonic therapy & LLLT.
-TENS & Interferential currents.
-Myofascial release techniques & IASTM.
-Core stability exercises.
-Postural correction techniques.
-Gentle mobilization techniques & MWM.
-Pelvic floor and pelvic rocking exercises.
-Gentle stretching exercises.
-Abdominal and hip extensors strengthening exercises.
-Ergonomic considerations.
-Avoidspinal manipulation to postpartumwomen.

45. 10-Symphysis pubis dysfunctions:
*Symphysis pubis diastasis is a rare cause of pelvic pain in pregnancy
but may be underdiagnosed.It is a complicationof pregnancyand
vaginal delivery in which the pubic symphysis separates, resulting in
acute pelvic pain, and may lead to severe long-term consequences.
Provocative tests(when positive, they are helpful in diagnosing SPD):
*Patrick’s Faber sign:
The test is positivewhen there is pain in
either sacroiliac joint or symphysis pubis.
*Active straight leg raise (ASLR)
*Flamingo test: Painat symphysiswhen
standing on one leg is a positivesign.

46. 11-Sacroiliac joint dysfunctions:
*Sacroiliac dysfunctionsare commonduring pregnancy and these
dysfunctions may continue after delivery (postpartum period).
*pregnancy-induced bone marrow edema at the sacroiliacjoints, as a
result of prolonged mechanical stress, was present in 63.3%of women
during the early postpartum period and may mimic sacroiliitis of axial spondylarthritis.
Provocative tests (when positive, they are helpful in diagnosing SI dysfunctions):
*Cluster of Laslett: *Passive extension and medial rotation of ilium on sacrum
-Posterior thigh thrust *Passive flexion and lateral rotation of ilium on sacrum
-Gapping test *Thomas test
-Compression test *Piriformis test
-Sacral thrust test *Leg length discrepancy
*Functional test of supine active straight leg raise
*Functional test of prone active straight leg raise

47. Physical Therapy Treatments for Sacroiliacand
Symphysis pubis dysfunctions
-Reassurance and Relaxation training.
-Hot packs:15-30 min. or Cold packs:10 min.
-Ultrasonic therapy ( Pulsed, Not Continuous)
-phonophoresis and Lidocaine iontophoresis.
-TENS & LLLT.
-Muscle energy tech. & trigger points release.
-Positional release (strain counter strain tech).
-Gentle mobilization techniques.
-Lumbopelvic supports and Kinesio tape.
-Core stability exercises.
-Stretching exercises.
-Strengthening exercises for ipsilateral hip extensors and contralateral latissimus dorsi.

48. 12-Coccydynia:
*Coccydyniais inflammationlocalized to the tailbone(coccyx).
*Symptomsand signsof coccydyniainclude focaldull aching painand
tenderness at the tailbone.
*Postpartum coccydynia is painthat appears as soon as a sitting position
is adopted after delivery. Coccyx morphology, body mass index, vaginal delivery,
instrumental delivery, multiparity, advanced maternal age and short perineum are risk factors.
*Childbirthis usually related to damageof the sacrococcygeal ligamentsduring vaginal
deliveryand the passageof the fetusthrough the birth canalmay cause acute trauma to the
coccyx, this can be further aggravatedby forceps delivery.
*Giving birth is one of themost common causes of coccydynia.
The coccyxbecomes more flexible towards the end of pregnancy.
This allowscoccyx, and sacrum, to bendand give way during labor.

49. Evidence of Physical Therapy
Treatments for coccydynia
*Patients with coccydyniaare initially advised toavoid
provocative factors. Initial treatment includesergonomic
adjustmentssuch as using a donut-shaped pillow or gel
cushion when sitting for a long period of time.
*Stretchingof piriformisand iliopsoasmuscles and
Maitland's rhythmic oscillatory thoracic mobilizationover
the hypomobile segments for 3 weeks, 5 sessions per
weekshowed significant improvement in pain pressure
thresholdand pain free sitting in patients with
coccydynia(Mohanty and Pattnaik, 2017).

50. *Extracorporeal shortwave therapy was more effective and satisfactory
in reducingdiscomfortand disabilitycaused by coccydynia3,000 shock
waves per session of 2 bar at 21 Hzfrequency directed to the coccyx
(Haghighat and Asl., 2016).
*Adequate pelvic floor muscle training can produce cranial movement of the coccyx tip
(Fujisaki et al., 2018).
*Combined manual therapy and corticosteroid injection were more effective in the
treatment ofCoccydyniaand patients following the treatment were completely pain free at the
end of the year (Chakraborty, 2012).
*Ultrasound therapy: Intensity-2w/cm2, Frequency-3MHZ,
Mode-continuousand Duration-10min. is an excellent non pharmacologic,
noninvasivemethod for alleviating post partum coccydynia(El-Mekawyet al., 2006).

51. 13-Dequervain’s tenosynovitis:
*De Quervain's tenosynovitis is a common wrist disorderinvolving
the abductor pollicis longus and extensor pollicis brevis tendonsof
the first dorsal compartment.
*Mild symptomsmay be present during the later stages of pregnancy
and then increase markedly at or shortly after delivery. Patients who
have persistent symptoms have reported that the activities of the
infant careoften aggravate the condition.
*Finkelstein's testis a test used todiagnosede Quervain's
tenosynovitisin people who havewrist pain.
Classical descriptions of the Finkelstein's test are when the examiner
grasps the thumb and ulnar deviates the hand sharply. If sharp pain
occurs along the distal radius, it is a positive sign.

52. Physical therapy for De quervain’s tenosynovitis
-Cryotherapy: for 10 min.
-TENS: If acute –high frequency TENS for 3o min.
If chronic –low frequency TENS for 15-20 min.
-Ultrasonic therapy:
If acute –3MHZ,0.5W/CM2,Pulsed 25% duty cycle.
If chronic –3MHZ,1W/CM2,continuous 100% duty cycle.
-Phonophoresis and Iontophoresis.
-Low Level Laser Therapy (LLLT).
-DTFand stretching exercises.
-Mobilization with movement technique (MWM).
-Graduated strengthening exercises.
-Splints and Ergonomic considerations.
-Kinesiotaping.

53. 14-Carpal tunnel syndrome:
*Carpal tunnel syndrome(CTS) is an entrapment neuropathy caused by
compressionof themedian nerveas it travels through the wrist's carpal tunnel.
and it is the most common nerve entrapmentneuropathy, accounting for
90%of allneuropathies.
*The main symptoms arepain,numbnessandtinglingin the thumb, index finger,
middle finger and the thumb sideof the ring finger. after a long period of time the
thenar musclesmay wasteaway.
*Carpal tunnel syndrome (CTS) is a frequent complication of pregnancy,
Butit may persist in 15% of postpartum women due tocare of baby.
*ThePhalen's test, reverse Phalen's test and Nerve conduction studies
(NCS) are usefulin diagnosis.

54. Physical therapy for Carpal Tunnel Syndrome
-Ice pack: for 10 min.
-Contrast baths: hot water (45°С) for 3min. then cold water (15°С) for 1min.
and repeatfor 3 times, Begin and endwith hot water.
-Ultrasonic therapy (Pulsed or Continuous) and phonophoresis.
-TENS.
-Low Level Laser Therapy (LLLT).
-Pulsed magnetic field therapy (PMFT).
-Myofascial release technique and DTF.
-Gentle stretching exercises.
-Carpal bone especially Scaphoid mobilization.
-Median nerve mobilization.
-Strengthening exercises for hand grip & ant. forearm ms.
-Ergonomic considerations, Splint & Kinesiotaping.