Int Urogynecol J DOI 10.1007/s00192-015-2684-y
REVIEW ARTICLE
The efficacy of physiotherapy for the prevention and treatment of prenatal symptoms: a systematic review Marijke Van Kampen 1 & Nele Devoogdt 1 & An De Groef 1 & Annelies Gielen 1 & Inge Geraerts 1
Received: 27 May 2014 / Accepted: 11 March 2015 # The International Urogynecological Association 2015
Abstract Several studies have described the evidence of prenatal physiotherapy for one symptom, but none has made an overview. We provided a systematic review on the effectiveness of prenatal physiotherapy. A full search was conducted in three electronic databases (Embase, PubMed/MEDLINE and PEDro), selecting randomized controlled trials concerning prenatal physiotherapy. Methodological quality was assessed using the PEDro scale. We identified 1,249 studies and after exclusions 54 studies were included concerning the evidence of prenatal physiotherapy. The majority of studies indicated a preventative effect for low back pain/pelvic girdle pain, weight gain, incontinence, and perineal massage. For leg edema, fear, and prenatal depression, the efficacy was only based on one study per symptom. No preventative effect was found for gestational diabetes, while literature concerning gestational hypertensive disorders was inconclusive. Regarding the treatment of low back pain/pelvic girdle pain and weight gain, most therapies reduced pain and weight respectively. Evidence regarding exercises for diabetes was contradictory and only minimally researched for incontinence. Foot massage and stockings reduced leg edema and leg symptoms respectively. Concerning gestational hypertensive disorders, perineal pain, fear, and prenatal depression no treatment studies were performed. The majority of studies indicated that prenatal physiotherapy played a preventative role for low back Electronic supplementary material The online version of this article (doi:10.1007/s00192-015-2684-y) contains supplementary material, which is available to authorized users * Inge Geraerts [email protected] 1
Department of Rehabilitation Sciences, KU Leuven, Tervuursevest 101, Post office box 1501, 3000 Leuven, Belgium
pain/pelvic girdle pain, weight gain, incontinence, and pelvic pain. Evidence for the remaining symptoms was inclusive or only minimally investigated. Regarding treatment, most studies indicated a reduction of low back pain/ pelvic girdle pain, weight gain, incontinence, and the symptoms of leg edema.
Keywords Antenatal . Childbirth . Pregnancy . Prenatal physiotherapy . Symptoms
Abbreviations ADL BMI C E EGWG FI GA GDM GHD GWG HR IOM LBP PFM PFMT PGP RCT SBP TENS UI VAS
Activities of daily life Body mass index Control group Experimental group Excessive gestational weight gain Fecal incontinence Gestational age Gestational diabetes mellitus Gestational hypertensive disorders Gestational weight gain Heart rate Institute of Medicine Low back pain Pelvic floor muscles Pelvic floor muscle training Pelvic girdle pain Randomized controlled trial Systolic blood pressure Transcutaneous electrical nerve stimulation Urinary incontinence Visual analogue scale
Int Urogynecol J
Introduction Prenatal physiotherapy is described to prevent and reduce symptoms during pregnancy and delivery, after childbirth, and in later life [1]. Pregnancy-related symptoms are low back pain (LBP), pelvic girdle pain (PGP), weight retention, gestational diabetes mellitus, urinary incontinence, fecal incontinence (solid, fluid, gas), gestational hypertensive disorders, preeclampsia, perineal pain, dyspareunia, leg edema, varicose veins, deep venous thrombosis, fear, depressive symptoms, leg cramps, morning sickness, fatigue, stretch marks, mood disorders, painful breasts, painful contractions postpartum, and postnatal depression. Although several studies have described the evidence of prenatal physiotherapy for one or two particular symptoms, none has made an overview of the evidence for using physiotherapy to treat all prenatal symptoms [2–55]. Furthermore, it is striking that, despite the multitude of studies, there is a great lack of knowledge regarding the evidence for using physiotherapy to treat prenatal symptoms. This also partly declares the variation in prescription behavior of physiotherapy by physicians and gynecologists among clinical settings. In addition, it is notable that different types of participants, symptomatic or asymptomatic, were recruited into several studies. Nevertheless, the following question has never been answered: BWhich prenatal symptoms can be prevented by prenatal physiotherapy? Do only symptomatic pregnant women need treatment for a particular symptom?^ In the literature no standardized exercise program for physiotherapy could be found. The programs differed with regard to type of exercise, intensity, type and duration of application, and the frequency and duration of the treatment sessions. The aims of our study were to provide a systematic literature review of clinical studies that investigated the effectiveness of prenatal physiotherapy in treating pregnancy-related symptoms.
primiparous, and multiparous women during pregnancy, receiving prenatal physiotherapy to prevent and/or reduce symptoms. Outcome measures were the occurrence, the reduction, the recurrence or the persistence of pregnancy-related symptoms. The heterogeneity among studies with regard to the duration of symptoms, interventions, and reporting of outcomes, precluded any extensive meta-analysis of the results.
Results The search of the databases, based on the different keywords resulted in 1,249 articles. Based on titles, 125 articles were selected. Second, based on abstracts, 78 articles remained, of which 54 articles were included in the review [2–55]. Four studies reported two symptoms, one study reported three symptoms. This resulted in 60 analyses and conclusions. The selection of the articles is described in Fig. 1. The different studies were categorized according to the symptoms they discussed. Most studies investigated one symptom; five studies investigated two or three symptoms [7, 22, 24, 26, 32]. In each symptom group the studies were divided into a preventative or a treatment study. Prevention means that all women without pregnancyrelated symptoms participated in the study. Treatment means that only the women with pregnancy-related symptoms participated in the study. In the Electronic supplementary material each study is described in detail, with an overview of the author and date, sample characteristics, a description of the treatment of the control and intervention groups, the intervention period, a description of the results, the PEDro score, and the power calculation. Additionally, Table 1 provides a summary of the main findings. The sequence of the symptoms in the text was based on the number of randomized studies, starting with the symptom with the highest number of studies.
Materials and methods Low back pain and pelvic girdle pain The databases Embase, PubMed/MEDLINE, and PEDro were searched up to 1 September 2013. The literature search was limited to articles in English, French, Dutch, and German. MeSH terms used at Pubmed/MEDLINE for this search were Bpain,^ Bbody weight,^ Bobesity,^ Burinary incontinence,^ Bfecal incontinence,^ Bcardiovascular diseases,^ Bperineum,^ Bedema,^ Banxiety,^ Bpregnancy complications,^ Bexercise therapy,^ Bexercise movement techniques,^ Bcounseling,^ Bexercise,^ Bmassage,^ Bphysical education and training,^ Brelaxation therapy,^ Bbandages,^ and Bpregnancy^. These MeSH terms were combined with the following general keywords: Bpain,^ Bweight,^ Bincontinence,^ Bdiabetes,^ Bperineum,^ articles included consisted of nulliparous,
Both LBP and PCP are reported to affect 45 % of all pregnant women at some time during pregnancy [16]. European guidelines recommend that LBP [57] and PCP [58] are managed by providing information, encouraging women to stay active, and by offering individualized exercises where appropriate. Seventeen randomized controlled trials, including a total of 3,964 women, contributed to the analysis of the effectiveness of prenatal physiotherapy on LBP and/or PGP [2–18]. Studies can be divided into three groups: a LBP group, a PGP group, and a mixed group with both symptoms. Each group is subdivided into a prevention group without LBP and/or PGP and a treatment group with LBP and/or PGP.
Int Urogynecol J Fig. 1 Selection of articles
Databases searched for articles with keywords + doubles removed N = 1249
Phase 1: Analyses titles
Inclusion N = 125
Exclusion: N =1124 Other type of study: 81 Other population: 707 No physical therapy: 167 Other outcome parameters: 88 Language: 30
PEDro score 26 kg/m2) no significant differences were found. Also, postpartum weight retention was strongly related to weight gain during pregnancy [19]. In the study of Hui et al. no significant difference was found between the exercise and dietary intervention compared with a group that was given only information on diet and activity [22]. Five studies compared the preventative effect of exercises alone with that of standard prenatal care [7, 23–26]. Cavalcante et al. and Price et al. found no significant differences in weight gain between the groups, regarding maternal weight gain, BMI or percentage of body fat during pregnancy [23, 24]. The other authors concluded that when attending the exercise training, consisting of aerobic and strength exercises, a significant weight reduction during pregnancy [7, 26] and at follow-up was found [27]. Finally, Huang et al. compared the effects of individual counseling on diet and physical activity on weight retention, starting from pregnancy (E1) or birth (E2) to 6 months postpartum with those of a standard prenatal care control group. The authors concluded that it is better to start diet and physical activity intervention during pregnancy to reduce postpartum weight retention [27].
Weight increase Prenatal treatment The Institute of Medicine recommends that women of normal weight, with a body mass index (BMI) between 19.8 and 26.0 kg/m2, gain between 11.4 kg and 15.9 kg during pregnancy and overweight women gain 6.8 to 11.4 kg. Weight increase can be defined as weight gain, indicating the gain in weight related to the pregnancy, and weight retention, indicating the maintenance of weight after delivery. According to a recent review dietary control, exercise, and eating behavior modifications are the main elements regarding controlling weight [59]. Fifteen randomized controlled trials were included concerning the effectiveness of prenatal physiotherapy on weight increase including a total of 2,469 women [7, 19–32]. The studies can be divided into two groups: a prevention group with or without excess weight or obesity and a treatment group with excess weight or obesity at the start of the study.
Five trials investigated the effect of physiotherapy as the treatment of excessive gestational weight gain in obese pregnant women between 10 and 24 weeks of gestational age [28–32]. Two studies compared pregnancy-specific diet and exercises with standard prenatal care [28, 29]. Phelan et al. found that a low-intensity behavioral intervention during pregnancy reduced excessive weight gain in normal weight women and prevented postpartum weight retention in normal weight and overweight/obese women [28]. Vinter et al. concluded that the intervention group improved dietary habits and gained significantly less weight than the control group [29]. Three studies compared the effect of exercises alone with that of standard prenatal care [30–32]. Santos et al. concluded that aerobic training in overweight pregnant women significantly increased the submaximal exercise capacity compared with the control group [30]. According to Nascimento et al., a
Int Urogynecol J
supervised exercise program was beneficial for lowering excessive gestational weight gain in overweight women [31]. Oostdam et al. could not find a favorable effect of exercises on gestational weight gain in overweight women [32]. Gestational diabetes mellitus The prevalence of GDM is about 6 % of pregnant women [34]. Nine randomized controlled trials investigated the effect of an exercise program to reduce the prevalence of GDM [22, 24, 26, 32–37]. Recent observational studies have found physical activity during normal pregnancy to decrease insulin resistance and therefore the rationale is that physical activity may help to decrease the risk of GDM [60]. A total of 3,996 women were included for analysis. The studies can be divided into a prevention group with or without GDM and a treatment group with GDM at the start of the study. Prenatal prevention In five studies, pregnant women were offered an aerobic exercise program and were compared with a group treated with usual care. The authors could not find any evidence that aerobic exercises prevented GDM [22, 24, 26, 32, 33]. Prenatal treatment Four studies randomized pregnant women with GDM, between 8 and 34 weeks of gestational age, into an exercise plus diet group or a control group who continued dietary therapy and usual physical activity [34–37]. Avery et al. performed an aerobic exercise program with a combination of supervised and home-based exercises, and compared this to no intervention. The aerobic exercise program resulted in a modest increase in cardio-respiratory fitness, but did not reduce blood glucose levels or prevent exogenous insulin therapy [34]. Brankston et al. compared a resistance training plus diet group to a control group receiving a standard diabetic diet. As a result the number of normal weight women requiring insulin did not differ between both groups. On the contrary overweight women experienced a beneficial effect of resistance training on GDM. In general, the amount of prescribed insulin was significantly lower in the diet + exercise group [35]. The study of de Barros et al. found a significant difference in the number of women using insulin, in favor of the exercise group [36]. Luoto et al. concluded that lifestyle counseling, concerning diet and physical activity, compared to standard prenatal care, did not treat GDM in overweight pregnant women [37].
Incontinence Urinary incontinence (UI) can occur in up to 30–50 % of pregnant women [44]. Seven randomized controlled trials were included, concerning the effectiveness of pelvic floor muscle training (PFMT) for pregnancy-related UI or fecal incontinence (FI) including 2,135 women for analysis [38–44]. The studies can be divided into two groups: a prevention group without incontinence and a treatment group with incontinence at the start of the study. European guidelines already indicated level A evidence, suggesting offering supervised PFMT, lasting at least 3 months, as a first-line therapy to women with stress or mixed incontinence [61]. Prenatal prevention Six randomized controlled trials were included concerning the effectiveness of perinatal physiotherapy on the prevention of incontinence [38–43]. The studies are divided into two groups: supervised antenatal PFMT or nonsupervised antenatal PFMT. Supervised vs nonsupervised antenatal PFMT The studies recruited nulliparous women [38, 40, 42] or multiparous women [39, 41] and randomized them to antenatal PFMT or standard prenatal care. Four studies found that PFMT resulted in fewer UI symptoms during late pregnancy [41] and after delivery [38–40]. On the contrary, Dannecker et al. found no significant differences between the intervention groups (daily PFMT with the Epi-No® device vs standard prenatal care) [42]. Morkved et al. concluded that intensive PFMT during pregnancy prevents urinary incontinence in about 1 in 6 women during pregnancy, and 1 in 8 women after delivery [38]. Furthermore, antenatal PFMT has an overall preventative effect on UI at least 3 to 6 months postpartum [38, 39]. Additionally, Morkved et al. also found higher pelvic floor muscle strength between the groups after PFMT [38]. Bo and Haakstad compared the effect of a general fitness class including PFMT with that of standard prenatal care in primiparous women [43]. No significant differences were found between the two groups regarding flatus, UI or FI [43]. Prenatal treatment Reilly et al. compared the effect of antenatal PFMT with giving information in nulliparous pregnant women with increased bladder neck mobility. Antenatal PFMT seemed to be effective in reducing the risk of postpartum stress UI [44].
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Gestational hypertensive disorders, preeclampsia Preeclampsia affects approximately 10 % of all pregnancies [62]. Four randomized controlled trials were included, concerning the effectiveness of physical activity on the prevention of preeclampsia or GHD, including a total of 281 women at risk of GHD before 14 weeks’ gestation [24, 45–47]. Regular exercise in people who are not pregnant is known to have general health benefits, including increased blood flow and reduced risk of high blood pressure. Thus, there is the potential for exercise to help prevent pregnant women developing preeclampsia [63].
pressure was applied. All three studies found a positive effect of antenatal perineal massage in reducing second- or thirddegree tears or episiotomies [48–50]. Shipman et al. found a stronger effect in the group aged 30 and older [50]. Further, Labrecque et al. concluded that massage therapy resulted in less pain 3 months postpartum in women with a previous vaginal birth. Among the pregnant women without previous vaginal birth there were no significant differences between the two groups with regard to perineal pain. Also, the frequencies of dyspareunia and incontinence, for urine, gas or stool, were similar in both groups [49]. Varicose veins, leg edema, and deep venous thrombosis
Prenatal prevention Yeo et al. showed that, after 10 weeks of aerobic exercises, the diastolic blood pressure decreased more in the exercise group than in the control group. Additionally, this near-significant blood pressure change was not caused by weight loss or overall daily physical activity, but by the exercises [45]. In a second study by Yeo et al. walking was compared with stretching. The incidence of preeclampsia was lower in the stretching group than in the walking group, 2.6 and 14.6 % respectively. Furthermore, only 22 % of the walking group had gestational hypertension compared with 40 % of the stretching women. Both results, however, only indicated a trend towards significance, as a sample size was too small [46]. One year later Yeo et al. found that pregnant women at risk of preeclampsia may benefit from the positive effects of exercise, but that adherence may be low [47]. Price et al. could not find any favorable effect of moderate aerobic exercises on developing GHD [24]. Perineal pain, dyspareunia Perineal trauma during childbirth is associated with dyspareunia and perineal pain. The most common cause of a perineal trauma is episiotomy. Even though the use of episiotomy is restricted, 50 % of women delivered without episiotomy have perineal trauma [48]. Three randomized controlled trials were included, concerning the effectiveness of prenatal physiotherapy for the prevention of perineal pain or dyspareunia caused by labor, including a total of 3,337 women for analysis [48–50]. Prenatal prevention All three studies described the effect of antenatal perineal massage [48–50]. The rationale is that perineal massage may increase the flexibility of the perineal muscles and therefore decrease muscular resistance, which would enable the perineum to stretch at delivery [64]. During perineal massage one to two fingers were inserted into the vagina and alternating downward and/or sideward
One-third of primiparous women and about 50 % of multiparous women have varicose veins after pregnancy. Varicose veins occur in approximately 28 % of pregnancies. Leg edema is found in about 80 % in late pregnancy [53]. Bamigboye and Smyth already indicated in 2005 that treatments for leg edema and varicosity had to include leg elevation, bed rest, whole body water immersion, and elastic compression stockings [65]. Three studies investigated the effectiveness of prenatal physiotherapy on varicose veins, leg edema, and deep venous thrombosis during pregnancy [51–53]. The studies can be divided into two groups: a prevention group without edema or varicose veins and a treatment group with edema or varicose veins at the start of the study. Prenatal prevention Kent et al. investigated the effects of static immersion and low-intensity water aerobics on pregnancy edema, and compared these with those of standing on land. The intervention groups had significantly larger diuretic and edema-relieving effects than standing on land [51]. Prenatal treatment Thaler et al. investigated the effects of two types of compression stockings on the reduction of leg edema in pregnant women. The first experimental group wore compression class I stockings (18–21 mmHg) on the left leg and class II stockings (25–32 mmHg) on the right leg. In the second group the compression classes were reversed. Both classes of compression stockings did not significantly prevent emergent varicose veins, but prophylactically improved leg symptoms related to varicose veins. The compression stockings, however, significantly decreased the incidence of long saphenous vein reflux at the sapheno-femoral junction [52]. Coban and Sirin compared foot massage with standard prenatal care in women with visible lower leg edema. The authors concluded that massage therapy had a positive effect on
Int Urogynecol J
decreasing normal physiological lower leg and feet edema in late pregnancy [53]. Fear
Adverse events No serious adverse effects could be noted for either the mother or the neonate in preventing and treating LBP [66], weight [59], gestational diabetes [60], incontinence [67], preeclampsia [63], and perineal pain [64]. As light to moderate physical activity during a normal pregnancy provides various benefits for the mother and her fetus, no adverse effects were found for the prevention of leg edema, fear, and prenatal depression [55, 60, 65, 68].
Fear of labor and anxiety are common complaints in women, with a prevalence of 6 to 30 % during pregnancy [54]. Only one study was included concerning the effectiveness of relaxation therapy in minimizing anxiety and stress responses, including a total of 110 pregnant women at between 14 and 28 weeks’ gestation [54]. Relaxation training is a method of anxiety management and has several other benefits [54].
Discussion
Prenatal prevention
Main findings and interpretation
Bastani et al. investigated the effect of relaxation training on anxiety and perceived stress, compared with standard prenatal care, in primiparous pregnant women. A significant decrease in state/trait anxiety and perceived stress was found for the experimental group [54].
This systematic review gave an overview of the effectiveness of different physiotherapy modalities on pregnancy-related symptoms during pregnancy. Fifty-four studies were included. Overall, the majority of studies regarding LBP/PGP confirmed the utility of exercises to decrease pain and disability [2–8, 16]. The literature is not conclusive concerning the use of a lumbopelvic belt, although most studies indicated no significant effect on pain [9–11]. Craniosacral therapy had a beneficial effect on morning pain, but more studies are warranted before recommending this therapy as treatment effects were small [12]. Nevertheless, regarding the positive effects of treatment, it is important to mention that at 3 weeks after delivery 75 % of patients were already pain free and 99 % at 3 months postpartum. A large proportion of pregnant women gain more weight than is recommended. It is however well known that excessive weight gain increases the risk of complications for both the mother and the infant [59]. A combination of diet and exercise had a significant effect on weight gain according to all but one study. Water aerobics made no difference in maternal weight gain during pregnancy [23]. Finally, aerobic exercise on land made a significant difference in maternal weight loss during pregnancy and postpartum in 5 out of 7 studies. Most studies regarding physiotherapy for GDM did not find a beneficial effect on prevalence or insulin use. However, one study indicated a significantly lower incidence of insulin use, but only in overweight, not obese women, when combining diet and exercise. Another study demonstrated less insulin use in pregnant sedentary women with GDM after performing resistance training. As incontinence occurs in a rather large percentage of pregnant women, PFMT is commonly recommended both during pregnancy and postpartum. Consequently, the majority of studies indicated a significant decrease in urinary incontinence in late pregnancy and postpartum. Two studies found no
Prenatal depression Worldwide, the prevalence of depression has been estimated to be 10 %. During pregnancy, depression affects 10–50 % of women, with the incidence being higher in cohorts with low socioeconomic status [55]. Guidelines from the American College of Obstetricians and Gynecologists [1] recommend regular exercise for pregnant women, including those who are sedentary, for its overall health benefits, including improved psychological health [55]. Only one study investigated the effect of a supervised aerobic exercise program on depressive symptoms in 74 nulliparous pregnant women [55]. Prenatal prevention Robledo-Colonia et al. concluded that a supervised 3-month program during pregnancy, consisting of walking (10 min), aerobic exercise (30 min), stretching (10 min) and relaxation (10 min) reduced depressive symptoms more than standard prenatal care [55]. Other symptoms No randomized controlled trials could be found concerning the effectiveness of prenatal physiotherapy on other symptoms such as leg cramps, morning sickness, fatigue, stretch marks, mood disorders, painful breasts, and painful contractions postpartum. No study with a PEDro score ≥5 investigated the effect of physiotherapeutic interventions performed during pregnancy to reduce depression after birth.
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beneficial effect of PFMT. Possible explanations could be that the training period was not long enough (from 37 weeks’ gestation until delivery) [42] or that the standard antenatal care of the control group was sufficient [43]. In summary, with regard to gestational hypertensive disorders, two studies could not indicate a significant decrease in blood pressure after at least 2.5 months of exercise training [24, 45]. Two other studies found a beneficial effect of exercise (walking/stretching) on the prevalence of preeclampsia and gestational hypertension [46, 47]. Women who performed digital perineal massage starting at approximately 35 weeks’ gestation were less likely to have perineal trauma after vaginal birth. Furthermore, a statistically significant reduction in the incidence of episiotomies could be found in women practicing digital perineal massage [48, 50]. Follow-up, however, indicated no differences in perineal symptoms and pain at 3 months postpartum [49]. Leg edema during pregnancy can be relieved by static immersion or water aerobics [51]. Furthermore, a foot massage relieves lower leg edema [53]. Stockings only help to decrease symptoms, but not to prevent varicose veins [52]. Pregnant women who followed additional relaxation training experienced a significant decrease in anxiety [54]. However, this finding was based on only one study: teaching relaxation techniques could serve as a resource for improving maternal psychological health. Depression affects a rather high percentage of women during pregnancy. However, only 1 RCT investigated techniques to prevent women from developing depressive symptoms. Robledo-Colonia et al. found that a supervised exercise program had a beneficial effect. The results of this study are consistent with earlier research regarding the effect of exercise on depressive symptoms in other populations [69]. In general, training sessions supervised by an experienced therapist appeared to be more effective. Recommendations concerning the start, the duration, and the number of treatments are difficult to make. Most programs started in the second trimester of pregnancy, with the exception of perineal massage that started just before delivery. Program duration was mostly between 8 and 16 weeks, but varied between 1 and 28 weeks. The number of guided treatments (4–36) varied widely depending on the content of the treatment and the type of symptom. Regarding the prevention and treatment of symptoms, the content of the physiotherapeutic program can be summarized as follows: land- or water-based exercises (global stretch and strength exercises, sitting pelvic tilt exercises, water gymnastics, stabilizing exercises, relaxation exercises, the use of a belt, and craniosacral therapy) for LBP/PGP, aerobic exercises combined with or without diet for a pregnancyrelated weight increase and to treat gestational diabetes mellitus, and supervised pelvic floor muscle training for urinary incontinence and perineal massage to prevent perineal pain. Furthermore, the literature was inconclusive regarding
the implementation of walking or stretching to prevent gestational hypertensive disorders. For leg edema a preventative effect could be found in static immersion or water aerobics, and compression stockings and foot massage treated varicose vein symptoms and lower leg edema respectively. Finally, only minimal research was done regarding relaxation training and aerobic exercises to prevent fear and prenatal depression respectively, although both studies indicated a preventative effect.
Strengths and limitations The strengths of this systematic review include searching three databases for RCTs regarding all prenatal symptoms. Furthermore, this systematic review is the first to provide an overview of the evidence for physiotherapy to treat prenatal symptoms as a whole. A literature search was done independently by four authors and disagreement was resolved in consensus meetings. Additionally, methodological quality was assessed using the PEDro scale, excluding RCTs with a score
REVIEW ARTICLE
The efficacy of physiotherapy for the prevention and treatment of prenatal symptoms: a systematic review Marijke Van Kampen 1 & Nele Devoogdt 1 & An De Groef 1 & Annelies Gielen 1 & Inge Geraerts 1
Received: 27 May 2014 / Accepted: 11 March 2015 # The International Urogynecological Association 2015
Abstract Several studies have described the evidence of prenatal physiotherapy for one symptom, but none has made an overview. We provided a systematic review on the effectiveness of prenatal physiotherapy. A full search was conducted in three electronic databases (Embase, PubMed/MEDLINE and PEDro), selecting randomized controlled trials concerning prenatal physiotherapy. Methodological quality was assessed using the PEDro scale. We identified 1,249 studies and after exclusions 54 studies were included concerning the evidence of prenatal physiotherapy. The majority of studies indicated a preventative effect for low back pain/pelvic girdle pain, weight gain, incontinence, and perineal massage. For leg edema, fear, and prenatal depression, the efficacy was only based on one study per symptom. No preventative effect was found for gestational diabetes, while literature concerning gestational hypertensive disorders was inconclusive. Regarding the treatment of low back pain/pelvic girdle pain and weight gain, most therapies reduced pain and weight respectively. Evidence regarding exercises for diabetes was contradictory and only minimally researched for incontinence. Foot massage and stockings reduced leg edema and leg symptoms respectively. Concerning gestational hypertensive disorders, perineal pain, fear, and prenatal depression no treatment studies were performed. The majority of studies indicated that prenatal physiotherapy played a preventative role for low back Electronic supplementary material The online version of this article (doi:10.1007/s00192-015-2684-y) contains supplementary material, which is available to authorized users * Inge Geraerts [email protected] 1
Department of Rehabilitation Sciences, KU Leuven, Tervuursevest 101, Post office box 1501, 3000 Leuven, Belgium
pain/pelvic girdle pain, weight gain, incontinence, and pelvic pain. Evidence for the remaining symptoms was inclusive or only minimally investigated. Regarding treatment, most studies indicated a reduction of low back pain/ pelvic girdle pain, weight gain, incontinence, and the symptoms of leg edema.
Keywords Antenatal . Childbirth . Pregnancy . Prenatal physiotherapy . Symptoms
Abbreviations ADL BMI C E EGWG FI GA GDM GHD GWG HR IOM LBP PFM PFMT PGP RCT SBP TENS UI VAS
Activities of daily life Body mass index Control group Experimental group Excessive gestational weight gain Fecal incontinence Gestational age Gestational diabetes mellitus Gestational hypertensive disorders Gestational weight gain Heart rate Institute of Medicine Low back pain Pelvic floor muscles Pelvic floor muscle training Pelvic girdle pain Randomized controlled trial Systolic blood pressure Transcutaneous electrical nerve stimulation Urinary incontinence Visual analogue scale
Int Urogynecol J
Introduction Prenatal physiotherapy is described to prevent and reduce symptoms during pregnancy and delivery, after childbirth, and in later life [1]. Pregnancy-related symptoms are low back pain (LBP), pelvic girdle pain (PGP), weight retention, gestational diabetes mellitus, urinary incontinence, fecal incontinence (solid, fluid, gas), gestational hypertensive disorders, preeclampsia, perineal pain, dyspareunia, leg edema, varicose veins, deep venous thrombosis, fear, depressive symptoms, leg cramps, morning sickness, fatigue, stretch marks, mood disorders, painful breasts, painful contractions postpartum, and postnatal depression. Although several studies have described the evidence of prenatal physiotherapy for one or two particular symptoms, none has made an overview of the evidence for using physiotherapy to treat all prenatal symptoms [2–55]. Furthermore, it is striking that, despite the multitude of studies, there is a great lack of knowledge regarding the evidence for using physiotherapy to treat prenatal symptoms. This also partly declares the variation in prescription behavior of physiotherapy by physicians and gynecologists among clinical settings. In addition, it is notable that different types of participants, symptomatic or asymptomatic, were recruited into several studies. Nevertheless, the following question has never been answered: BWhich prenatal symptoms can be prevented by prenatal physiotherapy? Do only symptomatic pregnant women need treatment for a particular symptom?^ In the literature no standardized exercise program for physiotherapy could be found. The programs differed with regard to type of exercise, intensity, type and duration of application, and the frequency and duration of the treatment sessions. The aims of our study were to provide a systematic literature review of clinical studies that investigated the effectiveness of prenatal physiotherapy in treating pregnancy-related symptoms.
primiparous, and multiparous women during pregnancy, receiving prenatal physiotherapy to prevent and/or reduce symptoms. Outcome measures were the occurrence, the reduction, the recurrence or the persistence of pregnancy-related symptoms. The heterogeneity among studies with regard to the duration of symptoms, interventions, and reporting of outcomes, precluded any extensive meta-analysis of the results.
Results The search of the databases, based on the different keywords resulted in 1,249 articles. Based on titles, 125 articles were selected. Second, based on abstracts, 78 articles remained, of which 54 articles were included in the review [2–55]. Four studies reported two symptoms, one study reported three symptoms. This resulted in 60 analyses and conclusions. The selection of the articles is described in Fig. 1. The different studies were categorized according to the symptoms they discussed. Most studies investigated one symptom; five studies investigated two or three symptoms [7, 22, 24, 26, 32]. In each symptom group the studies were divided into a preventative or a treatment study. Prevention means that all women without pregnancyrelated symptoms participated in the study. Treatment means that only the women with pregnancy-related symptoms participated in the study. In the Electronic supplementary material each study is described in detail, with an overview of the author and date, sample characteristics, a description of the treatment of the control and intervention groups, the intervention period, a description of the results, the PEDro score, and the power calculation. Additionally, Table 1 provides a summary of the main findings. The sequence of the symptoms in the text was based on the number of randomized studies, starting with the symptom with the highest number of studies.
Materials and methods Low back pain and pelvic girdle pain The databases Embase, PubMed/MEDLINE, and PEDro were searched up to 1 September 2013. The literature search was limited to articles in English, French, Dutch, and German. MeSH terms used at Pubmed/MEDLINE for this search were Bpain,^ Bbody weight,^ Bobesity,^ Burinary incontinence,^ Bfecal incontinence,^ Bcardiovascular diseases,^ Bperineum,^ Bedema,^ Banxiety,^ Bpregnancy complications,^ Bexercise therapy,^ Bexercise movement techniques,^ Bcounseling,^ Bexercise,^ Bmassage,^ Bphysical education and training,^ Brelaxation therapy,^ Bbandages,^ and Bpregnancy^. These MeSH terms were combined with the following general keywords: Bpain,^ Bweight,^ Bincontinence,^ Bdiabetes,^ Bperineum,^ articles included consisted of nulliparous,
Both LBP and PCP are reported to affect 45 % of all pregnant women at some time during pregnancy [16]. European guidelines recommend that LBP [57] and PCP [58] are managed by providing information, encouraging women to stay active, and by offering individualized exercises where appropriate. Seventeen randomized controlled trials, including a total of 3,964 women, contributed to the analysis of the effectiveness of prenatal physiotherapy on LBP and/or PGP [2–18]. Studies can be divided into three groups: a LBP group, a PGP group, and a mixed group with both symptoms. Each group is subdivided into a prevention group without LBP and/or PGP and a treatment group with LBP and/or PGP.
Int Urogynecol J Fig. 1 Selection of articles
Databases searched for articles with keywords + doubles removed N = 1249
Phase 1: Analyses titles
Inclusion N = 125
Exclusion: N =1124 Other type of study: 81 Other population: 707 No physical therapy: 167 Other outcome parameters: 88 Language: 30
PEDro score 26 kg/m2) no significant differences were found. Also, postpartum weight retention was strongly related to weight gain during pregnancy [19]. In the study of Hui et al. no significant difference was found between the exercise and dietary intervention compared with a group that was given only information on diet and activity [22]. Five studies compared the preventative effect of exercises alone with that of standard prenatal care [7, 23–26]. Cavalcante et al. and Price et al. found no significant differences in weight gain between the groups, regarding maternal weight gain, BMI or percentage of body fat during pregnancy [23, 24]. The other authors concluded that when attending the exercise training, consisting of aerobic and strength exercises, a significant weight reduction during pregnancy [7, 26] and at follow-up was found [27]. Finally, Huang et al. compared the effects of individual counseling on diet and physical activity on weight retention, starting from pregnancy (E1) or birth (E2) to 6 months postpartum with those of a standard prenatal care control group. The authors concluded that it is better to start diet and physical activity intervention during pregnancy to reduce postpartum weight retention [27].
Weight increase Prenatal treatment The Institute of Medicine recommends that women of normal weight, with a body mass index (BMI) between 19.8 and 26.0 kg/m2, gain between 11.4 kg and 15.9 kg during pregnancy and overweight women gain 6.8 to 11.4 kg. Weight increase can be defined as weight gain, indicating the gain in weight related to the pregnancy, and weight retention, indicating the maintenance of weight after delivery. According to a recent review dietary control, exercise, and eating behavior modifications are the main elements regarding controlling weight [59]. Fifteen randomized controlled trials were included concerning the effectiveness of prenatal physiotherapy on weight increase including a total of 2,469 women [7, 19–32]. The studies can be divided into two groups: a prevention group with or without excess weight or obesity and a treatment group with excess weight or obesity at the start of the study.
Five trials investigated the effect of physiotherapy as the treatment of excessive gestational weight gain in obese pregnant women between 10 and 24 weeks of gestational age [28–32]. Two studies compared pregnancy-specific diet and exercises with standard prenatal care [28, 29]. Phelan et al. found that a low-intensity behavioral intervention during pregnancy reduced excessive weight gain in normal weight women and prevented postpartum weight retention in normal weight and overweight/obese women [28]. Vinter et al. concluded that the intervention group improved dietary habits and gained significantly less weight than the control group [29]. Three studies compared the effect of exercises alone with that of standard prenatal care [30–32]. Santos et al. concluded that aerobic training in overweight pregnant women significantly increased the submaximal exercise capacity compared with the control group [30]. According to Nascimento et al., a
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supervised exercise program was beneficial for lowering excessive gestational weight gain in overweight women [31]. Oostdam et al. could not find a favorable effect of exercises on gestational weight gain in overweight women [32]. Gestational diabetes mellitus The prevalence of GDM is about 6 % of pregnant women [34]. Nine randomized controlled trials investigated the effect of an exercise program to reduce the prevalence of GDM [22, 24, 26, 32–37]. Recent observational studies have found physical activity during normal pregnancy to decrease insulin resistance and therefore the rationale is that physical activity may help to decrease the risk of GDM [60]. A total of 3,996 women were included for analysis. The studies can be divided into a prevention group with or without GDM and a treatment group with GDM at the start of the study. Prenatal prevention In five studies, pregnant women were offered an aerobic exercise program and were compared with a group treated with usual care. The authors could not find any evidence that aerobic exercises prevented GDM [22, 24, 26, 32, 33]. Prenatal treatment Four studies randomized pregnant women with GDM, between 8 and 34 weeks of gestational age, into an exercise plus diet group or a control group who continued dietary therapy and usual physical activity [34–37]. Avery et al. performed an aerobic exercise program with a combination of supervised and home-based exercises, and compared this to no intervention. The aerobic exercise program resulted in a modest increase in cardio-respiratory fitness, but did not reduce blood glucose levels or prevent exogenous insulin therapy [34]. Brankston et al. compared a resistance training plus diet group to a control group receiving a standard diabetic diet. As a result the number of normal weight women requiring insulin did not differ between both groups. On the contrary overweight women experienced a beneficial effect of resistance training on GDM. In general, the amount of prescribed insulin was significantly lower in the diet + exercise group [35]. The study of de Barros et al. found a significant difference in the number of women using insulin, in favor of the exercise group [36]. Luoto et al. concluded that lifestyle counseling, concerning diet and physical activity, compared to standard prenatal care, did not treat GDM in overweight pregnant women [37].
Incontinence Urinary incontinence (UI) can occur in up to 30–50 % of pregnant women [44]. Seven randomized controlled trials were included, concerning the effectiveness of pelvic floor muscle training (PFMT) for pregnancy-related UI or fecal incontinence (FI) including 2,135 women for analysis [38–44]. The studies can be divided into two groups: a prevention group without incontinence and a treatment group with incontinence at the start of the study. European guidelines already indicated level A evidence, suggesting offering supervised PFMT, lasting at least 3 months, as a first-line therapy to women with stress or mixed incontinence [61]. Prenatal prevention Six randomized controlled trials were included concerning the effectiveness of perinatal physiotherapy on the prevention of incontinence [38–43]. The studies are divided into two groups: supervised antenatal PFMT or nonsupervised antenatal PFMT. Supervised vs nonsupervised antenatal PFMT The studies recruited nulliparous women [38, 40, 42] or multiparous women [39, 41] and randomized them to antenatal PFMT or standard prenatal care. Four studies found that PFMT resulted in fewer UI symptoms during late pregnancy [41] and after delivery [38–40]. On the contrary, Dannecker et al. found no significant differences between the intervention groups (daily PFMT with the Epi-No® device vs standard prenatal care) [42]. Morkved et al. concluded that intensive PFMT during pregnancy prevents urinary incontinence in about 1 in 6 women during pregnancy, and 1 in 8 women after delivery [38]. Furthermore, antenatal PFMT has an overall preventative effect on UI at least 3 to 6 months postpartum [38, 39]. Additionally, Morkved et al. also found higher pelvic floor muscle strength between the groups after PFMT [38]. Bo and Haakstad compared the effect of a general fitness class including PFMT with that of standard prenatal care in primiparous women [43]. No significant differences were found between the two groups regarding flatus, UI or FI [43]. Prenatal treatment Reilly et al. compared the effect of antenatal PFMT with giving information in nulliparous pregnant women with increased bladder neck mobility. Antenatal PFMT seemed to be effective in reducing the risk of postpartum stress UI [44].
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Gestational hypertensive disorders, preeclampsia Preeclampsia affects approximately 10 % of all pregnancies [62]. Four randomized controlled trials were included, concerning the effectiveness of physical activity on the prevention of preeclampsia or GHD, including a total of 281 women at risk of GHD before 14 weeks’ gestation [24, 45–47]. Regular exercise in people who are not pregnant is known to have general health benefits, including increased blood flow and reduced risk of high blood pressure. Thus, there is the potential for exercise to help prevent pregnant women developing preeclampsia [63].
pressure was applied. All three studies found a positive effect of antenatal perineal massage in reducing second- or thirddegree tears or episiotomies [48–50]. Shipman et al. found a stronger effect in the group aged 30 and older [50]. Further, Labrecque et al. concluded that massage therapy resulted in less pain 3 months postpartum in women with a previous vaginal birth. Among the pregnant women without previous vaginal birth there were no significant differences between the two groups with regard to perineal pain. Also, the frequencies of dyspareunia and incontinence, for urine, gas or stool, were similar in both groups [49]. Varicose veins, leg edema, and deep venous thrombosis
Prenatal prevention Yeo et al. showed that, after 10 weeks of aerobic exercises, the diastolic blood pressure decreased more in the exercise group than in the control group. Additionally, this near-significant blood pressure change was not caused by weight loss or overall daily physical activity, but by the exercises [45]. In a second study by Yeo et al. walking was compared with stretching. The incidence of preeclampsia was lower in the stretching group than in the walking group, 2.6 and 14.6 % respectively. Furthermore, only 22 % of the walking group had gestational hypertension compared with 40 % of the stretching women. Both results, however, only indicated a trend towards significance, as a sample size was too small [46]. One year later Yeo et al. found that pregnant women at risk of preeclampsia may benefit from the positive effects of exercise, but that adherence may be low [47]. Price et al. could not find any favorable effect of moderate aerobic exercises on developing GHD [24]. Perineal pain, dyspareunia Perineal trauma during childbirth is associated with dyspareunia and perineal pain. The most common cause of a perineal trauma is episiotomy. Even though the use of episiotomy is restricted, 50 % of women delivered without episiotomy have perineal trauma [48]. Three randomized controlled trials were included, concerning the effectiveness of prenatal physiotherapy for the prevention of perineal pain or dyspareunia caused by labor, including a total of 3,337 women for analysis [48–50]. Prenatal prevention All three studies described the effect of antenatal perineal massage [48–50]. The rationale is that perineal massage may increase the flexibility of the perineal muscles and therefore decrease muscular resistance, which would enable the perineum to stretch at delivery [64]. During perineal massage one to two fingers were inserted into the vagina and alternating downward and/or sideward
One-third of primiparous women and about 50 % of multiparous women have varicose veins after pregnancy. Varicose veins occur in approximately 28 % of pregnancies. Leg edema is found in about 80 % in late pregnancy [53]. Bamigboye and Smyth already indicated in 2005 that treatments for leg edema and varicosity had to include leg elevation, bed rest, whole body water immersion, and elastic compression stockings [65]. Three studies investigated the effectiveness of prenatal physiotherapy on varicose veins, leg edema, and deep venous thrombosis during pregnancy [51–53]. The studies can be divided into two groups: a prevention group without edema or varicose veins and a treatment group with edema or varicose veins at the start of the study. Prenatal prevention Kent et al. investigated the effects of static immersion and low-intensity water aerobics on pregnancy edema, and compared these with those of standing on land. The intervention groups had significantly larger diuretic and edema-relieving effects than standing on land [51]. Prenatal treatment Thaler et al. investigated the effects of two types of compression stockings on the reduction of leg edema in pregnant women. The first experimental group wore compression class I stockings (18–21 mmHg) on the left leg and class II stockings (25–32 mmHg) on the right leg. In the second group the compression classes were reversed. Both classes of compression stockings did not significantly prevent emergent varicose veins, but prophylactically improved leg symptoms related to varicose veins. The compression stockings, however, significantly decreased the incidence of long saphenous vein reflux at the sapheno-femoral junction [52]. Coban and Sirin compared foot massage with standard prenatal care in women with visible lower leg edema. The authors concluded that massage therapy had a positive effect on
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decreasing normal physiological lower leg and feet edema in late pregnancy [53]. Fear
Adverse events No serious adverse effects could be noted for either the mother or the neonate in preventing and treating LBP [66], weight [59], gestational diabetes [60], incontinence [67], preeclampsia [63], and perineal pain [64]. As light to moderate physical activity during a normal pregnancy provides various benefits for the mother and her fetus, no adverse effects were found for the prevention of leg edema, fear, and prenatal depression [55, 60, 65, 68].
Fear of labor and anxiety are common complaints in women, with a prevalence of 6 to 30 % during pregnancy [54]. Only one study was included concerning the effectiveness of relaxation therapy in minimizing anxiety and stress responses, including a total of 110 pregnant women at between 14 and 28 weeks’ gestation [54]. Relaxation training is a method of anxiety management and has several other benefits [54].
Discussion
Prenatal prevention
Main findings and interpretation
Bastani et al. investigated the effect of relaxation training on anxiety and perceived stress, compared with standard prenatal care, in primiparous pregnant women. A significant decrease in state/trait anxiety and perceived stress was found for the experimental group [54].
This systematic review gave an overview of the effectiveness of different physiotherapy modalities on pregnancy-related symptoms during pregnancy. Fifty-four studies were included. Overall, the majority of studies regarding LBP/PGP confirmed the utility of exercises to decrease pain and disability [2–8, 16]. The literature is not conclusive concerning the use of a lumbopelvic belt, although most studies indicated no significant effect on pain [9–11]. Craniosacral therapy had a beneficial effect on morning pain, but more studies are warranted before recommending this therapy as treatment effects were small [12]. Nevertheless, regarding the positive effects of treatment, it is important to mention that at 3 weeks after delivery 75 % of patients were already pain free and 99 % at 3 months postpartum. A large proportion of pregnant women gain more weight than is recommended. It is however well known that excessive weight gain increases the risk of complications for both the mother and the infant [59]. A combination of diet and exercise had a significant effect on weight gain according to all but one study. Water aerobics made no difference in maternal weight gain during pregnancy [23]. Finally, aerobic exercise on land made a significant difference in maternal weight loss during pregnancy and postpartum in 5 out of 7 studies. Most studies regarding physiotherapy for GDM did not find a beneficial effect on prevalence or insulin use. However, one study indicated a significantly lower incidence of insulin use, but only in overweight, not obese women, when combining diet and exercise. Another study demonstrated less insulin use in pregnant sedentary women with GDM after performing resistance training. As incontinence occurs in a rather large percentage of pregnant women, PFMT is commonly recommended both during pregnancy and postpartum. Consequently, the majority of studies indicated a significant decrease in urinary incontinence in late pregnancy and postpartum. Two studies found no
Prenatal depression Worldwide, the prevalence of depression has been estimated to be 10 %. During pregnancy, depression affects 10–50 % of women, with the incidence being higher in cohorts with low socioeconomic status [55]. Guidelines from the American College of Obstetricians and Gynecologists [1] recommend regular exercise for pregnant women, including those who are sedentary, for its overall health benefits, including improved psychological health [55]. Only one study investigated the effect of a supervised aerobic exercise program on depressive symptoms in 74 nulliparous pregnant women [55]. Prenatal prevention Robledo-Colonia et al. concluded that a supervised 3-month program during pregnancy, consisting of walking (10 min), aerobic exercise (30 min), stretching (10 min) and relaxation (10 min) reduced depressive symptoms more than standard prenatal care [55]. Other symptoms No randomized controlled trials could be found concerning the effectiveness of prenatal physiotherapy on other symptoms such as leg cramps, morning sickness, fatigue, stretch marks, mood disorders, painful breasts, and painful contractions postpartum. No study with a PEDro score ≥5 investigated the effect of physiotherapeutic interventions performed during pregnancy to reduce depression after birth.
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beneficial effect of PFMT. Possible explanations could be that the training period was not long enough (from 37 weeks’ gestation until delivery) [42] or that the standard antenatal care of the control group was sufficient [43]. In summary, with regard to gestational hypertensive disorders, two studies could not indicate a significant decrease in blood pressure after at least 2.5 months of exercise training [24, 45]. Two other studies found a beneficial effect of exercise (walking/stretching) on the prevalence of preeclampsia and gestational hypertension [46, 47]. Women who performed digital perineal massage starting at approximately 35 weeks’ gestation were less likely to have perineal trauma after vaginal birth. Furthermore, a statistically significant reduction in the incidence of episiotomies could be found in women practicing digital perineal massage [48, 50]. Follow-up, however, indicated no differences in perineal symptoms and pain at 3 months postpartum [49]. Leg edema during pregnancy can be relieved by static immersion or water aerobics [51]. Furthermore, a foot massage relieves lower leg edema [53]. Stockings only help to decrease symptoms, but not to prevent varicose veins [52]. Pregnant women who followed additional relaxation training experienced a significant decrease in anxiety [54]. However, this finding was based on only one study: teaching relaxation techniques could serve as a resource for improving maternal psychological health. Depression affects a rather high percentage of women during pregnancy. However, only 1 RCT investigated techniques to prevent women from developing depressive symptoms. Robledo-Colonia et al. found that a supervised exercise program had a beneficial effect. The results of this study are consistent with earlier research regarding the effect of exercise on depressive symptoms in other populations [69]. In general, training sessions supervised by an experienced therapist appeared to be more effective. Recommendations concerning the start, the duration, and the number of treatments are difficult to make. Most programs started in the second trimester of pregnancy, with the exception of perineal massage that started just before delivery. Program duration was mostly between 8 and 16 weeks, but varied between 1 and 28 weeks. The number of guided treatments (4–36) varied widely depending on the content of the treatment and the type of symptom. Regarding the prevention and treatment of symptoms, the content of the physiotherapeutic program can be summarized as follows: land- or water-based exercises (global stretch and strength exercises, sitting pelvic tilt exercises, water gymnastics, stabilizing exercises, relaxation exercises, the use of a belt, and craniosacral therapy) for LBP/PGP, aerobic exercises combined with or without diet for a pregnancyrelated weight increase and to treat gestational diabetes mellitus, and supervised pelvic floor muscle training for urinary incontinence and perineal massage to prevent perineal pain. Furthermore, the literature was inconclusive regarding
the implementation of walking or stretching to prevent gestational hypertensive disorders. For leg edema a preventative effect could be found in static immersion or water aerobics, and compression stockings and foot massage treated varicose vein symptoms and lower leg edema respectively. Finally, only minimal research was done regarding relaxation training and aerobic exercises to prevent fear and prenatal depression respectively, although both studies indicated a preventative effect.
Strengths and limitations The strengths of this systematic review include searching three databases for RCTs regarding all prenatal symptoms. Furthermore, this systematic review is the first to provide an overview of the evidence for physiotherapy to treat prenatal symptoms as a whole. A literature search was done independently by four authors and disagreement was resolved in consensus meetings. Additionally, methodological quality was assessed using the PEDro scale, excluding RCTs with a score
