Inactivity: Symptoms Associated With Gastrocnemius Muscle Disuse During Pregnancy
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MCN Clinical Issues Volume 13, Number 2, pp. 248-262 @2002, MCN Inactivity: Symptoms Associated With Gastrocnemius Muscle Disuse During Pregnancy Judith A. Maloni, PhD, RN, FAAN; Barbara St. Pierre Schneider, DNSc, RN II This longitudinal study assessed change gastrocnemius muscle reoxygenation after in gastrocnemius muscle metabolism exercise significantly increased across across antepartum bed rest and recovery antepartum bed rest (t = -2.1, P < .05) and during the first 6 weeks postpartum as significantly decreased during the 6-week well as symptoms during recovery.The postpartum period (t = 1.83, P < .05). convenience sample consisted of 65 Women who were on bed rest prior to pregnant women, hospitalized on bed hospital admission had significantly higher rest for a mean of 24.8 days (range 5-70 reoxygenation scores upon enrollment (t = days). A dual wavelength hemoglobin! -8.6, P < .05). Symptoms of postpartum myoglobin spectrophotometer and muscle soreness, deconditioning, and ergometer assessed muscle difficulty with mobility were reported. reoxygenation times after plantar flexion Postpartum assessment and rehabilitation exercise from hospital admission through are needed to facilitate recovery and 6 weeks postpartum. The Postpartum prevent long-term injury. (KEYWORDS: Symptom Checklist assessed symptoms pregnancy, bed rest, inactivity, muscle of muscle deconditioning.The time for disuse, muscle deconditioning) Each year approximately 700,000 pregnant women who have been on antepartum bed women are prescribed antepartum bed rest rest are discharged from the hospital without for prolonged periods despite the lack of ev- an assessment of possible side effects, ad- idence of its effectiveness.l-4 Bed rest ther- vice about recovery, or a planned program apy during pregnancy is prescribed from of rehabilitation.3,7 To date, there has been weeks to several months by 89% to 92% of obstetricians, and the majority of them are .......... unaware of the side effects of this From the Frances Payne Bolton School of Nursing, treatment.' However, the physiologic side ef- Case Western Reserve University, Cleveland, Ohio (Dr fects of various types of activity restriction in MalonD; and the School of Nursing, University of Wis- consin, Madison (Dr Schneider). nonpregnant individuals are widely recog- nized.6 Many obstetric healthcare providers Reprint requests to Judith A. Maloni, PhD, RN, FAAN, Case Western Reserve University, Frances believe that because women are young and Payne Bolton School of Nursing, 10900 Euclid Av- healthy prior to pregnancy the effects of in- enue, Cleveland, OH 44106-4904 (e-mail: jam44@po. activity are negligible. Thus, after birth, cwru.edu). 248
Vol. 13, No.2 May 2002 PREGNANCY MUSCLE DISUSE . 249 minimal research examining the side effects induces significant change.9-11Deterioration of bed rest therapy among pregnant in the musculoskeletal system begins rapidly women.8 Only one study provides evidence within 6 hours of bed rest.I4-16Absolute loss that pregnant women demonstrate physio- of muscle mass and protein peaks during 3 logic side effects of bed rest that are similar to 7 days,17The most profound areas of atro- to those identified in nonpregnant popula- phy are in the postural muscles of the legs tions.3 Documentation of physiologic side and back. 6.18-20Greater loss occurs with even effects of bed rest in pregnant women is im- longer periods of inactivity.ll.18.19After 5 portant because bed rest treatment may weeks of bed rest, there is a 27% loss of place women at risk for both short- and strength in the plantar flexor muscles, in- long-term disability. Therefore, the purpose cluding the soleus and gastrocnemius.17 In of this study was to assess change in gastroc- one study, subjects demonstrated a 9% loss nemius muscle metabolism across antepar- in muscle volume in the lower back group, tum bed rest and postpartum recovery and 16% to 18% in the quadriceps and hamstring to describe the prevalence of symptoms as- groups, 20% in the ankle flexors, and 30% in sociated with recovery from musculoskeletal the ankle extensors after 17 weeks of space deconditioning after bed rest. flight.19The arms appear to be affected to a lesser degree but significant atrophy occurs if bed rest is prolonged.6,21Although there is o Review of Literature considerable variability in subjects, muscle volume loss appears to reach a steady state Inactivity occurs on a continuum ranging or plateau at approximately 4 months of from reduced activity to complete immobi- space flight.19 lization.6 Bed rest is one type of activity re- Differing models for the study of disuse striction and has been the focus of extensive atrophy reveal similar changes in muscle research. Aerospace scientists have used bed mass, protein, and strength. In animals, fiber rest as a model to study the effects of type and metabolic property changes occur weightlessness in space.9-11Research across in atrophied muscles.22,23For example, atro- more than 40 years documents that bed rest phied soleus muscle has fewer slow-twitch induces changes in every human physiologic fibers.23 Disuse muscle atrophy induces in- system.9-11The cause of bed rest side effects creased anaerobic capacity in slow-twitch is unclear but believed to be due to several and fast-twitch oxidative glycolytic fibers of factors. These factors include the lack of the soleus and gastrocnemius, respectively.23 weight bearing on the skeleton; decreased Data from a space flight study suggest simi- postural cues to the different organ systems; lar changes in anaerobic capacity in slow- decreased number and magnitude of muscle twitch fibers of the vastus latera lis muscle.24 contractions, particularly of the postural Therefore, it is possible that bed rest may in- muscles: and a headward bodily fluid duce alterations in muscle metabolism prop- shift.9.11The major adverse effect of bed rest erties of pregnant women. is a general physical deconditioning mani- Much is still unknown about recovery fested, in part, by alterations in circadian from inactivity because ethical issues limit rhythms and in cardiopulmonary, immune, the duration of bed rest research and space hormonal and musculoskeletal systems.9-11 flights are limited to small numbers of sub- Bed rest also results in insulin resistance in jects.6 However, recovery appears to be pro- the muscle and liver of women.12,13Of con- longed whether induced by bed rest or cern is that muscle contraction initiates glu- space flight.8.9.11Like initial deconditioning, cose uptake. Thus, whole body glucose various organ systems recover at different homeostasis may be altered by bed rest.12.13 rates.6.9.19Recovery begins with remobiliza- Being totally confined to bed, or in a Tren- tion and occurs slowly. In a study of 4 crew delenberg position, increases the severity of members after an 8-day space flight, ham- side effects.3.6.9 string and lower back muscles were still be- Organ systems deteriorate at different low baseline at 2 weeks after recovery.I8 rates across the same length of bed rest. During Mir space flights of 115 to 197 days, However, evena shortdurationof inactivity recovery of muscle volume was completed
250 . MALONI AND ST PIERRE AACN Clinical Issues for most individuals by 30 to 60 days after Because the majority of bed rest research flight.19 However, these results should be in- has been conducted on males and none on terpreted with caution as many astronauts pregnant women, it was unknown whether conducted intensive exercise during flight to pregnant women also experience muscu- offset anticipated losses. loskeletal changes induced during bed rest In a laboratory study of muscle recovery, and recovery from bed rest. During the last lower limb suspension was used to study the decade, research has begun to document the effects of muscle disuse. Six men were side effects of antepartum bed rest; however, placed on 4 weeks of lower limb suspension this research has primarily focused on the to mimic the effects of space flight. How- psychosocial side effects.35-38There is only ever, after 7 weeks of recovery, the ability to one published study documenting the physi- maintain force output was not fully ologic effects of bed rest during pregnancy.3 restored.25 Although muscle mass had re- Outcomes for 17 women on antepartum bed turned to normal, endurance remained sub- rest were compared with those for 18 optimal. Of further concern, it is not known healthy pregnant women who were not pre- whether the changes in musculoskeletal sys- scribed bed rest. Variables included antepar- tem are totally reversible.ll.19 tum and postpartum muscle reoxygenation Based primarily on animal studies, recov- time after exercise and postpartum symp- ery from muscle atrophy, in addition to be- toms of muscle recovery. Results revealed ing prolonged, appears to involve further that the time needed to reoxygenate the gas- muscle injury.6.26-30 Muscle damage and in- trocnemius muscle after a short bout of plan- flammation are evident soon after the re- tar flexion exercise increased as the length sumption of normal weight bearing.29.30Ex- of bed rest increased and decreased once ercise has been shown to cause muscle bed rest was terminated. Muscle reoxygena- damage, especially during the first week of tion times for the control group remained recovery.26.27It is possible that the damage low and stable across time. During recovery, occurs because the resumption of normal women who had been on bed rest reported weight bearing or exercise initially may be symptoms of deep muscle soreness of the too strenuous for atrophied muscles. Strenu- back, legs, arms, heels, and knees. Two ous activity, especially that involving muscle women experienced symptoms of a muscle lengthening, induces an acute muscle injury. tear. All women on bed rest had difficulty Similar to an exercise-induced muscle injury, walking, especially with ascending and de- repair and remodeling of the injured atro- scending stairs, while none in the control phied muscle occur eventually.29.31 group experienced these symptoms. Several symptoms, including muscle sore- An additional national retrospective study ness, swelling, and edema, are associated supports these findings (J.A.M., unpublished with recovery from muscle atrophy. These data, 2002). A randomly selected sample of symptoms are similar to those experienced 89 women who were prescribed antepartum by individuals who have undergone strenu- bed rest completed a checklist identifying ous or unaccustomed exercise. 32 Muscle the symptoms experienced during postpar- soreness usually develops within 24 to 48 tum recovery. Symptoms experienced by hours, peaks at 72 hours, then subsides at 5 more than 50% of women included back to 7 daYS.33Soreness is believed to be associ- muscle soreness; difficulty walking and in ated with muscle tissue damage. LeBlanc19 negotiating stairs, particularly when ascend- states that sore leg muscles often are re- ing; dizziness; shortness of breath; and fa- ported after both short and long space tigue. Symptoms that were reported by more flights. Muscle cramps, tears, strain, chronic than 25% of women included muscle sore- pain, and fatigue may be common during re- ness in arms, heels, knees, and upper and covery.33.34Swelling may be due to several lower leg muscles; knee buckling; swollen causes including inflammation or pooling of ankles or feet; and difficulty descending body fluids in the lower limbs. 19Thus, a vari- stairs. Nine percent of women reported post- ety of symptoms appear to occur during re- partum falls. Thus, current evidence suggests covery from muscle disuse and the cause(s) that pregnant women who are prescribed of these symptoms vary. antepartum bed rest experience symptoms
Vol. 13, No.2 May 2002 PREGNANCY MUSCLE DISUSE . 251 associated with muscle deconditioning dur- ing the postpartum, women who have previ- ing recovery, similar to those experienced in ously been on antepartum hospital bed rest nonpregnant populations. will demonstrate a decrease in muscle re- The presence of adverse physiologic ef- oxygenation time after exercise from an- fects of antepartum bed rest that extend into tepartum discharge through 6 weeks post- postpartum recovery is of concern for three partum as measured by T 1/2 muscle reasons. First, antepartum bed rest is pre- reoxygenation time. An additional research scribed for large numbers of women.2 Sec- question was to describe the symptoms as- ond, research has failed to document the ef- sociated with muscle deconditioning and re- fectiveness of bed rest for improving covery across the postpartum period. fetal/infant or maternal mortality or morbid- ity.2,7,8,39 Third, current data, which is consis- tent with that of aerospace research, now o Methods suggest that antepartum bed rest treatment has significant side effects. However, an- Women treated with antepartum bed rest tepartum bed rest therapy continues to be were assessed for symptoms of muscle dys- prescribed without apparent regard for these function using a repeated measures longitu- effects. 2,5 dinal design. Side effects such as muscle atrophy may place women at increased risk for long- Subjects term sequelae such as permanent muscle damage. Women may also be at risk for The convenience sample consisted of 65 fractures and an early osteoporosis as bed women who were studied from enrollment rest also induces bone 10SS.9,19Whether upon antepartum hospital admission such bone loss is totally reversible is not through 6 weeks postpartum. The data pre- known.1l,28 There is some evidence for an- sented here are for a subset of subjects who tepartum depression3 and for adverse an- participated in a larger study of the physio- tepartum psychosocial effects on the hus- logic and psychosocial side effects of an- band and the family.4,40If further evidence tepartum bed rest. Subjects were recruited about the adverse physiologic and psy- from the antepartum inpatient units of three chosocial side effects of antepartum bed tertiary care, university affiliated hospitals in rest is supported, it would suggest that an- two midwestern cities. Pregnant women di- tepartum bed rest treatment should not be agnosed with a pregnancy complication prescribed because it is both ineffective who were prescribed bed rest were eligible and iatrogenic. Therefore, the specific to participate. Criteria for inclusion were aims of this study were to determine women who were between 21 and 33 weeks whether women on antepartum bed rest gestation, at least 16 years of age, healthy demonstrate change in gastrocnemius prior to pregnancy, 'and able to read and muscle metabolism across time from an- speak English. Subjects were limited to tepartum hospital admission through 6 women with the diagnosis of preterm labor, weeks postpartum, and to describe the preterm rupture of membranes, placenta symptoms indicative of muscle decondition- previa, placental abruption, incompetent ing and recovery in the postpartum period. cervix, multiple gestation, or a combination of these conditions. Women were excluded if they had any acute or chronic metabolic o Hypotheses disease such as chronic hypertension, preg- nancy-induced hypertension, asthma, dia- During the antepartum, pregnant women on betes mellitus, an admission diagnosis of hospital bed rest will demonstrate an in- gestational diabetes, or any impairment in crease in muscle reoxygenation time after muscle function or mobility. exercise from hospital admission through Subjects were primarily white (63.1%), the end of antepartum hospitalization, as and married (60%), with ages ranging from measured in TI/z muscle reoxygenation time 16 to 40 (mean 28.0, SD 6.8). Years of mater- (TI/z = one half of the time in seconds). Dur- nal education ranged from 8 to 21 (mean
252 . MALONI AND ST PIERRE AACN Clinical Issues 13.9, SD 2.9) and 36% of women had globin! myoglobin (Hb/Mb) spectropho- household incomes at or below $30,000. tometer (Runman) invented by Dr Britton Most women were multigravidas (80%), al- Chance of the University of Pennsylvania. though only half of these had a living child. The Runman was used in the investigator's Women were diagnosed with preterm labor previous study and differentiated muscle re- (27.7%); preterm labor combined with an- oxygenation after short-term exercise for other of the above inclusion pregnancy di- women on bed rest and that of the control agnoses (33.8%); preterm rupture of mem- group of pregnant women not on bed rest.3 branes (18.5%); placenta previa (7.7%); The Runman examines muscle metabo- placental abruption (3.3%); or a combination lism by measuring oxygenation/deoxygena- of non-preterm labor diagnoses (9%). Eigh- tion of muscle tissue. The Runman has been teen percent of the pregnancies were multi- used to assess oxygenation of tissue in adult ple gestations. The gestational age of the brain after circulatory arrest after pacemaker pregnancy upon hospital admission ranged removal,41 as well as the oxygenation of the from 21 to 33 weeks (mean 28.4; SD 3.0), fetal brain,42 and respiratory muscle.43 The whereas the mean gestational age at birth Runman also has been used to assess reoxy- was 34.1 weeks (SD 3.3) and ranged from 24 genation of the quadriceps of 22 elite com- to 40 weeks. Sixty-six percent of women had petitive male and female rowers44 and in a vaginal delivery, 21.1% had an elective ce- three studies of the gastrocnemius muscle of sarean section, and 12.3% had an emergency non-pregnant, non-bed rest, subjects.45-47 cesarean section. The length of hospital bed Although the capability of the Runman to rest ranged from 5 to 70 days (mean 24.77, assess deoxygenation/reoxygenation re- SD 14.6). Twenty-six women (40%) were on sponses in a variety of populations has been bed rest at home prior to hospital enrollment validated, norms for various populations for a mean length of 22.7 days (SD 18.24, have not yet been established. range 2-89). The Runman pulses near red light waves (760 and 850 nm) through superficial tissue Measures to obtain signals from the Hb/Mb content of the muscle during exercise and exercise re- A list of variables and instruments used to covery.44The difference in absorption at the assess them is given in Table 1 two wavelengths approximates desaturation MUSCLE METABOLISM. Measurement of mus- of Hb/Mb during exercise and resaturation cle disuse in high-risk pregnant women during recovery.44,48-50A small-rubberized placed on bed rest presented unique chal- encasement (probe) about the size of a large lenges as standard methods of muscle as- wristwatch containing silicon diodes and in- sessment involve rigorous activity and are terference filters is placed over the muscle contraindicated.3 Anthropometric measure- and secured by a Velcro band. Light waves ment, muscle biopsy, and magnetic reso- penetrate through superficial tissue to pick nance imaging were considered but re- up signals of deoxygenation and resatura- jected because of lack of reliability, tion of the muscle. The Runman is combined excessive cost or discomfort, or potential with a portable ergometer (pedal) to con- danger to the fetus. Therefore, muscle me- duct plantar flexion exercise so that patterns tabolism was assessed using the new exper- of deoxygenation in response to exercise imental noninvasive dual wavelength hemo- can be observed. Signals of oxygenation and TABLE1. Study Variablesand Instruments Variable Instrument Muscle metabolism Hemoglobin/myoglobin spectrophotometer and ergometer Postpartum muscle symptoms Postpartum symptoms checklist Postpartum mobility Postpartum symptoms checklist
Vol.13, No.2 May 2002 PREGNANCYMUSCLEDISUSE . 253 deoxygenation are recorded by a strip chart muscle fatigue. The exercise took on the av- recorder (Figure 1). The amount of time in erage approximately 3 minutes and did not seconds needed to recover from exercise to induce full body fatigue. Monitoring and a baseline level of reoxygenation after exer- graphing of reoxygenation of muscle after cise divided by 2 (T 1/2 recovery time) is exercise took an additional 2 minutes. The used as the score.44 Longer muscle reoxy- exercise did not appear to affect decondi- genation times indicate prolonged recovery tioning resulting from muscle disuse. from oxygen-induced debt stimulated by ex- POSTPARTUM SYMPTOMS. Postpartum symp- ercise.44 Use of the Runman poses no risk or toms associated with muscle disuse were as- discomfort to the person. sessed with a self-report Postpartum Symp- Two teams of two data collectors tested tom Checklist. The checklist consists of 49 subjects in their hospital rooms using a stan- items, which assess the influence of bed rest dardized protocol.3 One directed the exer- upon the various organ systems. Only symp- cise while the other operated the Runman toms associated with muscle disuse (n = 12) and strip chart recorder. Women sat in bed or mobility (n = 7) are reported here. The in a semi-Fowlers position with legs ex- checklist was developed by the investigator tended and knees fixed (Figure 2). The gas- based on clinical experience with women on trocnemius muscle was used for assessment bed rest and from an extensive review of the of muscle disuse because it is a postural literature on bed rest and pregnancy. Items weight-bearing muscle. It consists of pre- assessing mobility were adapted from re- dominately slow oxidative Type I fibers that search with the elderly5253as a simple, effec- alter their contractile speed and enzymatic tive, and inexpensive method of assessing capacity when weight bearing is removed. 51 gross mobility problems among young, This muscle is superficial to the skin and healthy subjects had not been developed. thus is easily accessible for measurement. Items assess whether the person (1) needs The probe was placed over the gastrocne- support to walk; (2) hesitates before walk- mius muscle and covered with a lightly ing; (3) walks using each foot alternately; (4) wrapped ace bandage to prevent the escape experiences difficulty with knees buckling; of light. Women conducted intermittent has difficulty (5) ascending or (6) descend- plantar flexion exercises by pressing on a ing stairs; or (7) has difficulty transferring to pedal against 10 pounds of pressure for a a sitting position. Appropriateness of the distance of 5 inches. Plantar flexions were items was judged by peer review. Items executed once every 10 seconds until a were tested and revised to include other baseline of deoxygenation was achieved, symptoms identified in the pilot study. In a then once every 5, 2, and 1 second, and then subsequent study, the Postpartum Symptom maximal effort until the woman reported Checklist distinguished symptoms between Figure1. Patternfor deoxygenationduringexercisetestingandreoxygenationduring recovery from exercise.
254 . MALON! AND ST PIERRE AACN Clinical Issues Hb/Mb Spectrophotometer ! Strip Figure 2. Setup for spectrophotome- Recorder ter (Runman) testing. women on bed rest and pregnant women data collection, with the exception of two who did not receive bed rest.4 Cronbach al- days after delivery, occurred in the subjects' pha was established at O. 84. The symptom homes. A baseline measure of muscle me- checklist was administered by the data col- tabolism was obtained upon hospital admis- lector and scored as present or absent. The sion, and at the end of the antepartum, and checklist took approximately 3 to 4 minutes at 6 weeks postpartum. Postpartum symp- to complete. tom data were collected at 2 days after deliv- DEMOGRAPHICS. An expanded form of the ery and weekly through 6 weeks. Demo- Demographic and Medical History Instru- graphic and perinatal data were obtained ment3 was used to obtain descriptive data upon enrollment and updated using the from the hospital record and from patient in- medical record as new conditions emerged. terview. Information about maternal demo- Subjects received a $50 incentive for partici- graphic and perinatal characteristics includ- pating in the study. ing sample descriptor variables such as previous history of home and hospital bed rest for this and previous pregnancies was o Statistical Analyses obtained. PROCEDURE. The medical records of poten- Data were analyzed using the Statistical tial subjects were screened for their appro- Package for the Social Sciences (SPSS) 10.0 priateness for entry into the study. Informed for windows. Descriptive statistics and Stu- consent was obtained after study approval dent t tests were computed. Power was cal- by the Human Subjects Boards. Enrollment culated for the larger study containing multi- of subjects occurred over a 3.5-year period. ple variables and nine hypotheses. 54For the Six weeks of data collector training was con- current analysis. hypotheses were directed ducted prior to enrollment of subjects. After for one group of bed-rested women with training, data collectors had to successfully three assessments across time. However, assess gastrocnemius muscle metabolism us- upon analyzing the perinatal data we de- ing the Runman on 10 different women, at tected a change in the characteristics of the least 3 of whom had to be on bed rest. Due bed rest treatment across the study. When to the complexity of the Runman instrument, the study was initiated, pregnant women procedural reliability was reassessed approx- were admitted directly to the hospital for imately every 2 months on a random sched- bed rest and remained there until delivery. ule. Interrater reliability for the Postpartum However, across time home bed rest began Symptom Checklist was established and re- to be prescribed prior to hospital admission. assessed quarterly to maintain reliability of As a result the sample consists of both 0.95. women whose bed rest was started upon hospitalization (n = 39) and women whose Data Collection bed rest was initiated prior to hospitalization (n = 26). Because muscle atrophy occurs Antepartum data collection took place while rapidly,l1 the sample was divided into these each subject was hospitalized. Postpartum tWo groups for part of the analysis to detect
Vol. 13, No.2 May 2002 PREGNANCY MUSCLE DISUSE . 255 the influence of home bed rest prior to ad- bed rest subjects was not appropriate at this mission. Thus using a one tailed t test, alpha time, as they may represent values of a pop- set at 0.05, posthoc power was estimated at ulation to which generalization about effects 0.52 with an effect size of 0.45. need to be made. Given that the power was low but the ef- fect size was moderate to high, options were considered to address the low power. De- o Results creasing within group variability would in- crease power. However, the Runman is a During antepartum bed rest, the length of new experimental assessment tool. The va- time needed for women's gastrocnemius lidity of the tool for assessing oxygenation! muscle to reoxygenate after exercise signifi- deoxygenation of tissue has been estab- cantly increased from hospital admission lished but the range of normal values has through discharge (t = -2.1, P < .05). In not yet been established. Furthermore, the contrast, the length of time needed for post- state of. the science in understanding the partum muscle reoxygenation after exercise physiologic effects of muscle atrophy upon significantly decreased (t = 1.83, P < .05). pregnant women is limited. In the absence Figure 3 demonstrates the pattern of change of norms, the variability in muscle reoxy- across the three time periods. Despite signif- genation scores might represent some factor icant differences in muscle reoxygenation as yet unknown. Thus, we were hesitant to scores across time, women's scores demon- eliminate outliers. strated great variability. The type of delivery Furthermore, although the standard devi- (ie, vaginal versus cesarean section) did not ations for muscle reoxygenation scores were influence postpartum muscle reoxygenation large, similar standard deviations were found scores. in a previous study of 31 healthy pregnant Because 40% of the women were on women using the Runman (J.A.M., unpub- bed rest prior to hospital admission, sub- lished data, 2002). Whether or not the range jects were divided into two groups. The of values contains true outliers is unknown groups consisted of those women who at this time. However, strip chart recordings were not on bed rest prior to hospital ad- for eight subjects who appeared to have ex- mission (n = 39) and those who were (n = treme outliers were reviewed. Three test 26). Muscle reoxygenation scores were sig- scores were eliminated due to a scoring er- nificantly higher upon enrollment for those ror. The remaining tests appeared to be valid who had previously been on bed rest (t = and were included in the data set. Therefore, -8.6, P < .05) but not significantly different it was decided that elimination of outliers for at the end of the antepartum or postpartum E 44 E= = 42 - .~ ~ ~ 40 ~ ~ ~ 38 IX .E 36 Cj
256 . MALONI AND ST PIERRE AACN Clinical Issues periods. Figure 4 depicts the patterns for (Table 4). Support to walk was needed muscle reoxygenation scores for the two across the first week postpartum for a num- groups. Variability among reoxygenation ber of women and more than 40% needed scores was greater among women who help to sit. Initially, more than 50% of were prescribed home bed rest prior to women hesitated before beginning to walk. hospital admission (Table 2). Most women (77%) began using stairs during The prevalence of musculoskeletal de- the first week at home. Difficulty negotiating conditioning symptoms occurring from 2 stairs started at this time. For some women, days after delivery through 6 weeks postpar- stair-climbing difficulties and knee buckling tum is listed in Table 3. Soreness in weight- persisted across 6 weeks postpartum. bearing postural muscles dominated the symptoms reported by women. Soreness in back and neck muscles, followed by upper o Discussion and lower leg soreness, were reported most frequently and decreased across 6 weeks. A The current study demonstrates that in- large percentage of women also initially re- creases in the time needed for the gastrocne- ported arm muscle soreness. At 6 weeks mius muscle to reoxygenate during the an- postpartum, 45% of women were still experi- tepartum decrease during the first 6 weeks encing back muscle. soreness and 21% had postpartum. Additionally, the development persistent neck muscle soreness. Only a few of symptoms of recovery from muscular de- women reported muscle tears. Fatigue, conditioning and difficulty with mobility pedal edema, and shortness of breath on ex- during the first 6 weeks postpartum was ertion were greatest immediately after birth confirmed in the current study. These results with only high levels of fatigue remaining at support the supposition that muscle atrophy 6 weeks. occurs during antepartum bed rest and re- Assessment of mobility revealed that dur- covers with remobilization.6.9.1l,28Using a ing postpartum women experienced diffi- summary of studies, Fortney et al9 created a culty in all seven areas of walking, which composite description of physiologic re- rapidly improved across 6 weeks postpartum sponses during bed rest recovery. They re- 44 E E: 42 = 0 40 = 38 i / "- 1- Bedrest No Prior 36 "- 34 I 1 / 1- -Prior Bedrest - -- N Eo- 32 30 First Last Last Antepartum Antepartum Postpartum Figure 4. Gastrocnemiusmuscle reoxygenationtime afterexerciseforwomenwho wereprescribedbed rest prior to hospitalizationand thosewhowerenot.
Vol. 13, No.2 May 2002 PREGNANCYMUSCLEDISUSE . 257 TABLE2. Variabilityin MuscleReoxygenation Scores First Antepartum Last Antepartum Last Postpartum Mean ~ SO Mean ~ SO Mean ~ SO No previous bed rest 31.04::t: 15.43 41.72::!: 16.66 34.59 ::!: 16.36 Previous bed rest 39.64 ::!:23.24 39.78:!: 19.88 36.69 ::!:22.56 port that subjects demonstrated generalized on home bed rest were significantly higher weakness; poor exercise tolerance; distur- at admission but no additional change oc- bance of coordination, posture, and gait; curred across hospitalization. The lack of foot pain; difficulty standing without sup- change in the prior bed rest group suggests port: difficulty walking; and leg pain. The that, at some point, bed rest atrophy reaches current study results agree with this compos- a plateau similar to astronauts.19 This finding ite and confirm our previous findings for is also consistent with reports that other or- pregnant women on bed rest.3.39Study re- gan systems adapt physiologically to this sults also support findings of atrophy in non- state across time.9,1l pregnant subjects on bed rest or those par- Longer inactivity is usually accompanied ticipating in space flight.9.11.18-20 In women by greater atrophy and longer recovery, 11,19 without a prior bed rest history, the steep in- so it was expected that a longer period of in- crease in muscle reoxygenation times across activity would proportionally affect muscle the antepartum supports the rapid onset of metabolism as evidenced by a prolonged muscle deconditioning or atrophy soon after muscle reoxygenation time. Muscle reoxy- bed rest is started.9.11,18-20 genation scores for women on home bed Comparisons for the two groups of rest prior to admission remained slightly ele- women, one of which had been on bed rest vated at six weeks postpartum. However, no prior to admission, reveal additional under- significant difference in postpartum muscle standing of the muscle atrophy process. The reoxygenation was detected between the muscle reoxygenation scores for the women two groups of women. It is possible that no TABLE 3 . Postpartum Symptoms of Deconditioning Delivery* Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 n=62 n=60 n=64 n=58 n=64 n=62 n=64 No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) Upper legs sore 24 (38.7) 21 (35.0) 17 (26.6) 8 (13.8) 8 (12.5) 3 (4.8) 4 (6.3) Lower legs sore 18 (29.0) 24 (40.0) 15 (23.4) 12 (20.7) 8 (12.5) 5 (8.1) 5 (7.8) Arms sore 17 (27.4) 15 (25.0) 10(15.6) 6 (10.3) 7 (10.9) 5 (8.1) 8 (12.5) Neck sore 21 (33.9) 20 (33.3) 15 (23.4) 14 (24.1) 17 (26.6) 11 (17.7) 14 (21.9) Back sore 44 (71.0) 35 (58.3) 27 (42.2) 23 (39.7) 25(39.1) 24 (38.7) 29 (45.3) Heel sore 13 (21.0) 11 (18.3) 7 (10.9) 5 (8.6) 7 (10.9) 6 (9.7) 5 (7.8) Knee sore 9 (14.5) 7 (11.7) 7 (10.9) 7 (12.1) 8 (12.5) 9 (14.5) 8 (12.5) Muscle cramps 28 (45.2) 18 (30.0) 13 (20.3) 5 (8.6) 9 (14.1) 3 (4.8) 9 (14.1) Muscle tears 0(0) 1 (1.7) 1 (1.6) 0(0) 1 (1.6) 0(0) 1 (1.6) Shortness of breath 23 (37.1) 19(31.7) 16 (25.0) 8 (13.8) 6 (9.4) 8 (12.9) 6 (9.4) Fatigue 46 (74.2) 44 (73.3) 40 (62.5) 32 (55.2) 32 (50.0) 27 (43.5) 34(53.1) Pedal edema 26 (41.9) 24 (40) 11 (17.2) 6 (10.3) 6 (9.4) 6 (9.7) 4 (6.3) "Delivery time point was measured postpartum day 2,
258 . MALONI AND ST PIERRE AACN Clinical Issues TABLE 4 . Postpartum Mobility Symptoms Delivery* Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 n=62 n=60 n=64 n=58 n=64 n=62 n=64 No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) Hesitates before walking 34 (54.8) 26 (43.3) 8 (12.5) 3 (5.2) 4 (6.3) 1 (1.6) 2 (3.1) Needs support to walk 19 (30.6) 12 (20.0) 3 (4.7) 2 (3.4) 1 (1.6) 1 (1.6) 1 (1.6) Knees buckle 8 (12.9) 8 (13.3) 6 (9.4) 4(6.9) 3 (4.7) 4 (6.5) 4 (6.3) Needs support to 28 (45.2) 15 (25.0) 6 (9.4) 3 (5.2) 1 (1.6) 2 (3.2) 2 (3.1) sit down Does not alternate 10 (16.1) 7 (11.7) 3 (4.7) 2(3.4) 3 (4.7) 2 (3.2) 1 (1.6) feet when walking Difficulty ascending 3(4.8) 20 (33.3) 13 (20.3) 9 (15.5) 6 (9.4) 4 (6.5) 5 (7.8) stairs Difficulty descending 3 (4.8) 16 (26.7) 7 (10.9) 5 (8.6) 5 (7.8) 2 (3.2) 5 (7.8) stairs "Delivery time point was measured postpartum day 2. difference was detected because of the large Further research regarding women's symp- variability in reoxygenation scores, because toms after 6 weeks postpartum is needed. both groups reached the maximum amount Postpartum soreness in neck and arms is of atrophy at the last antepartum measure- somewhat surprising. Neck muscle soreness ment, or because muscle metabolism as was reported in our previous study3 but measured by reoxygenation time after exer- LeBlanc et aP8.19expressed surprise at failing cise does not increase linearly with longer to find neck muscle soreness as the head is inactivity. A larger sample size, more precise heavy. However, during space flight, the full measurement of the amount of time spent weight of the head is still supported by the out of bed, and more frequent measurement neck whereas during bed rest, the bed and of reoxygenation time during the antepar- pillow support the head most of the time. tum period may resolve this issue. Consider- Neck muscle soreness could also be a result ation of variations in the sample such as age, of pushing during delivery as even small ethnicity, and weight might also shed light amounts of strenuous exercise can induce into this finding. muscle damage during recovery. Arm mus- Muscle soreness in the various postural cle soreness is not ordinarily expected in muscles dominated initial postpartum recov- bed rest lasting less than 60 days.6 During ery. This finding is consistent with reports the antepartum period, women use their that muscle tissue damage occurs during re- arms for a number of self-care activities. mobilization.19.28.34Because a large percent- However, during the postpartum period age of women continued to experience women often report that they use their arms back and neck muscle soreness at 6 weeks to pull themselves up stairs and as crutches postpartum, it suggests that long-term, more when descending stairs, sitting down, or serious muscle damage, or prolonged recov- during toilet transfer. Arm muscle soreness ery form injury has occurred. It is possible may result from greater antepartum atrophy that female hormonal shifts that women ex- than has been reported among nonpregnant perience during the postpartum may be, in populations or muscle injury during the part, responsible. Preliminary animal evi- postpartum activities to compensate for leg dence suggests that female hormones may muscle weakness. affect leukocyte infiltration, an important Postpartum fatigue during recovery is not process for the recovery of injured muscle.55 surprising but is likely to be confounded Long-term muscle soreness also may indicate with childrearing fatigue. Lee and Zaftke56 that muscle atrophy is not entirely reversible. report high levels of fatigue among healthy
Vol. 13, No.2 May 2002 PREGNANCY MUSCLEDISUSE . 259 mothers because of fragmented sleep. Fur- o Nursing Implications ther study may reveal whether the fatigue experienced by those previously on bed rest The implications of these findings for nurs- is different in magnitude or quality. ing are numerous. In the absence of elimi- Postpartum symptoms disappeared rapidly nating pregnancy bed rest treatment, a com- for most women. Women are highly moti- mon thought is to prevent atrophy by using vated to resume ambulation to care for the antepartum exercise. Astronauts have at- infant. Early ambulation may be helpful in tempted to do so but have only been par- tially successful. 6.28 The type of exercise restoring function but women may be prone to falls. This is of grave concern for two rea- needed to offset atrophy is intensive and in- sons. First, women may be carrying their in- volves heavy resistance training.6 This type of exercise is not conunonly used by healthy fants and both could be injured during a fall. Second, aerospace research shows a women and is currently contraindicated dur- strong correlation between bed rest induced ing a high-risk pregnancy. However, an- muscle loss and bone loss, with recovery of tepartum exercise involving increased bone lagging behind that of muscle.6.9.19 weight bearing might help reduce muscle at- Thus, during resumption of walking women rophy. In addition, a systematic assessment of muscle weakness and an accompanying may also be at risk for fractures, particularly at the point when muscles have reached program of postpartum rehabilitation may facilitate recovery and prevent long-term in- their maximal strength but bone has not.6 Women's muscle reoxygenation scores jury of muscle and bone. After inactivity, the goal is to enable exhibited a large degree of variability across women to return to a normal level of physi- time, especially for those on previous home cal activity without injury.34 A number of bed rest. Several explanations could account measures will facilitate maternal recovery for this finding. First of all, aerospace re- and are suggested for nursing practice. searchers have found variability in muscle These include assessing for: atrophy obtained by a variety of assessment methods.19 Researchers using the Runman in nonpregnant samples have also found large . the type of physical activity conducted prior to bed rest to know what kinds of variability (personal communication, Chance, March, 2001). However, the vari- B. . activity the woman will resume; the duration of home and hospital bed rest ability for our pregnant sample is somewhat larger than expected. The variability could be due to measurement error, variations in . and the severity of activity restriction; muscle weakness to determine which muscle groups are most seriously af- the length of bed rest among the sample (range 5-70 hospital days), or the influence of subject activity. All women were allowed . fected by bed rest; symptoms of difficulty walking, de- creased strength, fatigue, and other out of bed each day to go to the bathroom symptoms associated with muscle recov- and it is not uncommon for women to walk to the bathroom 10 to 13 times per day. While such trips usually last 5 minutes or . ery and ambulation-induced injury; symptoms of postpartum depression asso- ciated with postpartum loss of function less, some women linger for longer periods. and independence or antepartum stress; and Variability could also indicate that preg- nancy might influence muscle metabolism in some way that is not yet understood. A . family problems related to the stress of having a high-risk pregnancy. large degree of variability was also demon- Nurses also should advise the woman to: strated in our study of healthy pregnant women who were not on bed rest (J.A.M., . begin weight-bearing activity to facilitate unpublished data, 2002). Additional re- search is needed to clarify these issues. Fur- . recovery; . remobilize carefully to avoid overusing ther research is needed to define the range of normal values for deoxygenation re- sponse to exercise among healthy and high- . muscles and inducing further damage; exert caution as there is a potential for falls due to knee buckling and decreased risk pregnant women. leg strength;
260 . MALONI AND ST PIERRE AACN Clinical Issues · rebuild back and leg muscles through gradual exercise as these muscle groups to document women's postpartum com- plaints about muscle dysfunction, muscle · are most likely to be weak; consult with a healthcare professional who is familiar with both exercise and soreness, physical limitations that inhibit en- gagement in activities, and the time at which women reach full postpartum functional ca- assessment of muscle function and de- pacity after antepartum bed rest. · conditioning about postpartum exercise; exert caution even when muscle groups reach normal functioning as bone mass is o Summary still in the process of restoration; · expect limited strength, fatigue, and Pregnant women who are prescribed bed muscle soreness as a result of pregnancy rest experience significant changes in mus- · bed rest treatment; report symptoms after bed rest to their healthcare provider; cle metabolism while hospitalized and a sig- nificant reversal of these changes in the postpartum. The postpartum period is also · use acetaminophen, if possible, instead characterized by symptoms commonly asso- of nonsteroidal anti-inflammatory drugs ciated with recovery from muscle (NSAIDS) for symptom relief, as NSAIDS atrophy / deconditioning. Numerous nursing may interfere with macrophage function actions can facilitate maternal postpartum re- · and delay recovery from injury; expect that fatigue might occur during physical activity and that function, inde- covery and prevent long-term injury to mus- cle and bone. pendence, and mobility eventually will Acknowledgments be restored; · increase sufficient protein intake to en- This study is funded by a grant from the Na- sure muscle repair, especially in later tional Institute of Health, National Institute part of the muscle recovery period. of Nursing Research ROI-NRO-3323. The au- thor thanks Sarah Korkowski for her assis- Patient referrals will be necessary for: tance. · an in-depth assessment of muscle weak- ness and development of a planned pro- gram of rehabilitation, and References · obtaining instrumental support for assis- tance with completing household tasks. 1. Enkin M, Keirse M, Renfrew M, Neilson J. A Guide to Effective Care in Pregnancy and Childbirth. 2nd ed. New York: Oxford Uni- In addition, the results have major impli- cations for research. Further research is versity Press; 1995. needed in this population to determine 2. Goldenberg RL, Cliver SP, Bronstein J, Cutter GR, Andrews WW, Mennemeyer ST. Bed rest whether recovery of muscle mass is accom- in pregnancy. Obstet Gynecol. 1994;84:131- panied by a return of endurance. Endurance 136. among subjects on bed rest has rarely been 3. Maloni J, Chance B, Zhang C, Cohen A, Betts studied, and anecdotal evidence from our D, Gange S. Physical and psychosocial side subjects indicates that recovery of muscle effects of antepartum hospital bed rest. NuT'S function is not accompanied by endurance. Res. 1993;42:197-203. There has not been any research about the 4. Maloni J, Tomasi J, Johnson L. Antepartum optimal mode, duration, and intensity of ex- bed rest: effect upon the family. J Obstet Gy- ercise training that bed rest patients can use necol Neonatal NuT'S.2001;30:165-173. to minimize musculoskeletal deconditioning. 5. Maloni J, Cohen A, Kane J. Prescription of ac- tivity restriction to treat high-risk pregnan- Additional research is needed regarding the cies. J Womens Health. 1998;7:165-173. recovery of other organ systems. Lastly, 6. Bloomfield SA. Changes in musculoskeletal complaints about postpartum symptoms af- structure and function with prolonged bed ter bed rest often are dismissed because of rest. Med Sci Sports Exerc. 1997;29:197-206. lack of physician awareness of the side ef- 7. Maloni J. Bed rest and high-risk pregnancy: fects of bed rest. Further research is needed differentiating the effects of diagnosis, setting
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