Page Ten P H Y S I O T H E R A P Y July, 1954. POST-NATAL REHABILITATION By R O SE M A R Y H A R T E , m .c .s. p . IN M Y opinion, the ideal is to start within a few hours o f the birth o f the baby. U nfortunately the average physiotherapist has no access to the patient at this stage, bu t those m others who have attended pre-natal classes m ay have instruction with dem onstrations. When this is possible, there are four simple exercises which should n o t unduly tax any norm al patient, whether o r no she has stitches. The psychological effect is very considerable, the patient realising th a t it is up to her to rehabilitate herself, and the m ental and physical stim ulation brings rem arkable rewards. I am now referring to private patients, where very often the physiotherapist does not feel justified in com m itting the patient to a visiting fee for a very short treatm ent in the first tw o days. Where the p atient is in an institution where routine physiotherapy is provided, this is naturally carried out from the first day. T he four exercises referred to are: (1) C rook lying, knees squeezing together, tightening the glutei and draw ing up the pelvic floor. I usually teach this with a sucking in o f the abdom inal- wall (not an abdom inal contraction) in the hopes th a t the p artial vacuum caused in the abdom en may help to draw up the pelvic floor. (2) C rook lying, abdom inal breathing with abdom inal contractions. This exercise w orks the straight abdom ­ inal muscles in their entire range. C are must be takem to see th at the patient flattens her spine into the bed until the Recti become taut, a t the finish o f the exercise. T oo often patients feel they are tightening their a b ­ dom inal muscles when they suck them in as in exercise 1, which has no value as a n abdom inal exercise since - it is, in effect, stretching them concavely. (3) Lying with ankles crossed, squeezing knees together, tightening glutei and sucking in abdom en while pulling up the pelvic floor. Similar to num ber 1, but with a slight difference in the stress o f the muscles. (4) Lying with a rm s'fo ld e d , or to the side, head and shoulder raising. This is a strong abdom inal muscle exercise. I f these exercises are carried out conscientiously, (a little and often throughout the day being preferable to ' one daily session to the point o f fatigue), the effects should be: ^ (1) When the m other first gets up, she should in some measure, be able to control her abdom inal 'muscles. (2) T he average p a tie n t'w h o has done no exercises will tell you th a t on first rising she feels as if she had “ a large hole in her nether end through which her inside was prepared to drop at any m om ent.” T h at sen­ sation, plus overstretched abdom inal muscles produce th a t gait peculiar to w omen who have ju st delivered . . . rather hunched, with knees pressed together and hands clasped firmly to the protruding abdom en. They seem quite incapable o f w alking naturally. This should be obviated if these exercises have been conscientiously done. (3) Should the p atient be left with some measure o f stress incontinence, she should be able to alleviate it, and possibly cure it completely herself. In the good old days when the patients lay abed for ten days, it was advisable to give exercises for the toes, ankles and quadriceps as well. In these enlightened days o f early rising, I personally feel th a t this is unnecessary. N ow we come to the debatable subject of binders. Binders appeared to go put when early rising came in, and I can elicit no satisfactory reason from doctors. O ne. even did me the honour o f trying them out on several patients, but stated th at it was quite unsatisfactory as they rolled into a little bunch in the waist in less time than the telling. O ther doctors, no doubt, have a shrewd suspicion that if a patient wears a binder, she relaxes her abdom inal wall against it, with a sigh o f relief, and takes no further p art in the re-education o f her muscles. M y ideas on the subject are here for your acceptance o r rejection. (1) I am definitely in favour of them providing they a r e , o f the two-way stretch variety which can better b^f controlled th an calico, linen, etc. (2) I would only sanction their use providing the patient were intelligent and had been instructed that they were an adjunct to exercises and not to be used instead o f them . This is most im portant. (3) I f the abdom inal muscles are stretched, it is much easier to w ork .them hard in the im portant inner range, w hen they are supported some o f the way. (4) Even with a conscientious patient, the am ount o f time per day taken up with exercises is extremely small in a 24-hour day. W hen the patient is not doing h er exercises, they are probably hanging or lying in an overstretched position, which I consider bad. ' O n or after the third day, the patient should be ready for full treatm ent, having laid the foundation herself. I know th at some people think th a t exercises alone are sufficient, but, having given the m atter much thought, I feel th at abdom inal massage in the first ten days is so beneficial th a t it should not be om itted if possible. It is very stim ulating to the circulation, refiexly affecting the tone o f the muscles and colon, and helping constipation which is so often present. A little special attention to the uterus helps to empty it and furthers involution. I do not consider th at massage to the limbs is necessary if the patient has been allowed up early, neither do I feel th at, if abdominal, massage has been given in the first two weeks, it is o f very great benefit after that. Exercises alone should then suffice. Occasionally one is asked to massage for engorged breasts, a lengthy process if the breasts are to be emptied, but m ore often than not the nursing staff consider it their prerogative. Exercises being the most im portant factor, these are progressed daily according to the capacity o f the patient, and include work for the straight and oblique abdom inal muscles, the pelvic floor, posture and the breasts. I am not going to bore you with a detailed description o f these exercises, they are too familiar to the average physiotherapist. By the 8th o r 9th day the patient should be doing a full scheme o f exercises, the benefit o f w hich cannot be over­ stated. It is interesting to hear the opinions o f patients who have had babies with and w ithout treatm ent. They consider there is no comparison. They go hom e feeling fit and able to cope with a new baby and housew ork without th a t ghastly sense o f fatigue which limits their activities and causes a certain am ount o f depression. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) July, 1954. P H Y S I O T H E R A P Y Page Eleven While in the hospital, the nursing staff usually instruct the patients as a m atter o f routine, to spend a certain am o un t of their rest period in the prone lying position. The physio­ therapist should'check and see th a t this is being done. A s regards physiotherapy after a C aesarian section, I feel that these patients need it m ore than any others, as their period of rehabilitation is m ore protracted. A n experienced physiotherapist can help them- enorm ously in the first few days with very gentle abdom inal massage to help dispel flatus, and carefully graded exercises, starting with static abdom inal contractions. One m ust remember th at psychologically these patients start a t a disadvantage, and very often treatm ent dispels their vision o f them self as a very sick person w ho m ust lie quite still for days. Their abdom inal muscles and posture need far m ore re-educating than those o f the w om an who has delivered norm ally, and yet, funnily enough, these are the patients we see least of in practice. . ' If there are facilities, patients can start class work a t a jm onth to six weeks. I find if left to themselves, they seldom do their exercises a t hom e, and the stim ulation and com­ petition o f class w ork appeals to them. O n the other hand a large percentage cannot m ake suitable arrangem ents for leaving their babies, and it should be stressed th a t in this case, they m ust w ork a t hom e if they wish to complete the treatm ent. In conclusion, I w ould like to say th at I feel th a t p o st­ natal treatm ent should be routine in obstetrics, bu t I do realise th at there is a financial side to it in private practice, which sometimes defeats its own ends. D e liv e r a n c e . . . from pain .... the hum anitarian function of of the p ra ctitio n er .... now accomplished with g r e a te r speed, more economy an d with a higher degree o f safety than e v er before. ' Full d e ta ils and clin ica l notes on th e use of R E N O T I N in th e tre a tm e n t o f M ig ra in e , N e uritis, Lumbago, Sprains and M yalgia may be o b ta in e d from E xclusive D istributors fo r Southern A fr ic a V _ y I A s U C / lA * P H A R M A C E U T IC A L S LTD . m -Sk P.O. BOX 7 7 9 3 ' J O H A N N E S B U R G O N R E H A B I L I T A T I O N . . . A Medical Congress spotlighting REHABILITATIO N could have included no worthier associates than the members of the Society of Physiotherapists. + + + Their lifework revolves around Rehabilitation.- T o this task they are . dedicated. + + + W e are proud to be able to claim a share in their success by putting som e of the finest tools into their able hands. IH ie d U a i SPECIALISTS FOR PH YSICA L MEDICINE APPLIAN CES P.O. Box 3378. JO H A N N E S B U R G . Tel. 23-8106. Telegraphic Address: "DISM ED." O ffice and Showroom at 2 3 6 , JEPPE STREET. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )