Occupational Therapists’ Role in Perinatal Care: A Health Promotion Approach

Carpal Tunnel Syndrome

Hand and wrist pain is the most common musculoskeletal complaint in pregnancy after back pain and, if left untreated, can progress to a chronic condition (Balık et al., 2014). Carpal tunnel syndrome (CTS) is typically cited as a common cause of this discomfort (Borg-Stein & Dugan, 2007; Rozali et al., 2012). The inability to use one or both hands secondary to pain and weakness is debilitating and can affect one’s occupational engagement in daily life. In a Level 3 prospective cross-sectional study, Balık et al. (2014) randomly selected 383 perinatal women to investigate the prevalence of hand and wrist pain in pregnancy. The results indicated that 67.4% of the participants had symptoms, which may be attributable to a change in the hormone prolactin and the fluid retention associated with pregnancy (Borg-Stein & Dugan, 2007). Peripheral neuropathies can occur if prolonged periods of swelling and poor positioning are incorrectly managed. These conditions can persist during the postpartum period. What begin as transient paresthesias in the hands can lead to maladaptive, compensatory postures, increasing the risk of tendinosis up the kinetic chain. Poor positioning during repetitive activities involved with child care can exacerbate pain in not only the wrist but also the elbow (epicondylosis) and shoulder (rotator cuff tendinopathy) as well as the neck (Balık et al., 2014; Borg-Stein & Dugan, 2007).

Research has also shown that pregnant women expect pain and discomfort during pregnancy and therefore do not disclose their difficulties to their doctor. It is likely that actual symptom prevalence is grossly underreported unless patients are directly asked about their musculoskeletal pain (Sapuan et al., 2012). According to Borg-Stein and Dugan (2007), education regarding correct positioning of the hands and body during child care (feeding, carrying, and bathing) should be given prenatally as well as after the birth to reduce the discomfort associated with CTS.

In a rare Level 1 study specifically linking pregnancy and nerve compression, Padua et al. (2010) conducted a systematic review to assess the incidence of pregnancy-related CTS and to document its natural course. They found that many factors are still unknown regarding why a commonly occurring condition in pregnancy (between 31% and 62% in their sample) happens to some women and not others. The authors recommended that, considering a high resolution rate of CTS in this population, surgical measures are not advised and that the first mode of treatment should be conservative, that is, therapy. On the basis of their inclusion criteria, Padua et al. (2010) considered the Boston Carpal Tunnel Syndrome Questionnaire (Levine et al., 1993) to be a validated and reliable outcome measure for patients with CTS that can be used by occupational therapists to monitor outcomes.

De Quervain’s Tenosynovitis

De Quervain’s tenosynovitis (see Mayo Clinic, 2018) is a common condition involving the inflammation of two tendons of the thumb and wrist, namely the abductor pollicis longus and the extensor pollicis brevis (Sharma et al., 2015). Each time the thumb and wrist are deviated, these tendons are engaged. Add weight, movement, and continuous repetition, as when picking up a baby all day long, and the opportunity for acutely painful tenosynovitis at the wrist presents. When left untreated, De Quervain’s, or “mommy thumb,” can result (Walkinshaw, 2011). Research has confirmed that De Quervain’s is common in pregnancy and even more common than CTS in the postpartum period (Balık et al., 2014). According to Werner et al. (2005), De Quervain’s was the third most reported tendon disease in the UE in people with physically demanding occupations. What is more physically demanding and exhausting than taking care of a young child?

A survey study conducted by Ring and Schnellen (2009) examined how a patient-centered approach (patient assists in choosing surgery, injection, therapy, or no intervention) for De Quervain’s would affect outcomes. The authors did not explicitly address the perinatal population, although, out of the 314 patients surveyed, a percentage would likely have developed De Quervain’s secondary to pregnancy or in the postpartum period. The results indicated that De Quervain’s can be viewed as a self-limiting illness and that there was no statistical difference between patients who waited for 12–18 mo versus those who underwent injection likely within the first 12 mo of initial symptoms. Patients who opted for surgery had immediate relief but undertook associated surgical risks and recovery time. New mothers may be less inclined to undergo surgery given that this means an interruption in breastfeeding and caring for their child during recovery.

After conducting a systematic review on De Quervain’s outcomes, Cavaleri et al. (2016) emphasized a multimodal approach versus specific isolated treatments (injection, orthoses). In addition, Rogozinski and Lourie (2016) struggled to find conclusive evidence regarding the satisfaction of patients who underwent surgery for De Quervain’s at long-term follow-up (1 yr after surgery). Research does not support surgery or injection as the definitive solution when treating De Quervain’s.

Health Promotion

Corbett et al. (2014) conducted a Level 3 cross-sectional study that examined barriers to women seeking early prenatal care specifically in a low-income region of New Zealand. The results indicated that women from lower socioeconomic backgrounds are less likely to come under prenatal management at earlier stages of their pregnancies (i.e., before 18 wk) and are less likely to have a spouse or partner to provide them with support throughout their pregnancy and the birth of their child. Considering the delay with seeking health care management, this group is at higher risk for musculoskeletal injury during pregnancy.

Occupational therapists can get involved through health promotion before issues arise by educating the physician or health care practitioner (HCP) about the value of occupational therapy for appropriate referral, because physicians and HCPs will likely be the first point of contact for these women. Occupational therapists are uniquely suited to address this problem through preventive occupations, which Scaffa and Sasse (2014) defined as “the prevention of disease and disability and the promotion of health and well-being of individuals and communities through meaningful engagement in occupations” (pp. 26–27). There is also an opportunity for occupational therapists in community settings to establish awareness of their role during the perinatal period because most people are unaware that this skill set within occupational therapy exists.

As occupational therapists continue to merge health care and technology—specifically, social media platforms—they can take advantage of this communication platform to better inform patients of their services and to educate them in preventive and health promotion strategies during the perinatal period. Using qualitative methodology, Asiodu et al. (2015) researched the role of social media among African-American women and their support persons during pregnancy and the postpartum period. To ensure trustworthiness, credibility, transferability, dependability, and conformability were maintained, and the authors described the use of reflexivity, member checking, and descriptive analysis. This research can also be used to inform other demographic groups. This study poses opportunities for occupational therapists looking to use technology to create content that relates to mother and child and educates the public on the role of occupational therapy. In addition, participants from Asiodu et al.’s study expressed motivation to continue to learn about their health through social media, implying opportunities for education on posture, strengthening, positioning, and tips and advice to remain healthy and strong.

Social media outlets are a widely available and rapidly growing area for knowledge dissemination and should be seriously considered as part of the modern health care approach. A way to capitalize on the social media boom is to use existing pregnancy applications and incorporate an exercise component for expectant mothers as well as symptoms to be aware of and to report to their HCPs, for example, a pop-up on the app (e.g., as on a smartphone) detailing common signs of CTS (progressive numbness, tingling, night pain, weakness in the hands) and letting users know that they should bring this to their HCP’s attention and see an occupational therapist for management options. Using social media’s influence will strengthen and broaden occupational therapy’s reach and exposure to the public.

Discussion

Little evidence currently exists to demonstrate the link between our profession and new and expectant mothers. However, occupational therapists can have a powerful impact on the occupational performance of this population. Society needs mothers to be independent and healthy so they can take care of their and their family’s occupational needs. Creating a role for occupational therapy with this population further connects our community to achieve occupational balance and performance, a key component of the American Occupational Therapy Association’s (AOTA’s) Occupational Therapy Practice Framework: Domain and Process (3rd ed.; AOTA, 2014).

Law et al.’s (1996) Person–Environment–Occupation (PEO) model provides occupational therapists with a comprehensive therapeutic approach and structure for holistic, client-centered analysis. This model defines the person as an individual with multiple roles and responsibilities and is particularly appropriate for new mothers. The model considers the physical, emotional, and spiritual needs of the mother within a specific cultural context and her interactions and decisions regarding her baby. The person aspect of the PEO model addresses performance components such as motor abilities, strength, coordination, and endurance—all factors that influence self- and child care. If the mother’s home environment is supportive, she is more likely to rest and less likely to injure herself through repetitive tasks and poor postures. Emotional support and validation from the household, community, and legislation will also reduce stress and the likelihood of developing health issues (Dennis & Dowswell, 2013).

In addition, new mothers must learn new activities, tasks, and occupations related to child care. Practicing these repetitive activities, such as holding the baby correctly during breastfeeding and lifting and carrying the child, is crucial to avoid injury. Fluidity, efficiency, and pain-free motion affect the occupation of caring for the baby while continuing to perform certain self-care (showering, dressing, personal hygiene) and household (cooking, cleaning, laundry, and caring for additional children) roles and occupations. The PEO model assumes that, for occupational performance to occur, all of these factors (the individual, context, and activities) need to function in a harmonious fashion. Townsend and Wilcock (2004), experts on the topic of occupational justice and balance, discussed how the inability to perform an occupation leads to occupational discord or imbalance.

In a landmark article in 1977, Engel proposed a frame of reference to include not only the biomedical aspects of the patient’s life but also the social, psychological, and behavioral components. He termed this the biopsychosocial model and envisioned that it would be a “blueprint for research, a framework for teaching, and a design for action in the real world of health care” (p. 135). Many years later, this frame of reference remains relevant to and appropriate for the perinatal population. Also, themes examining the physical, social, and psychological factors and their interactions are woven into the Framework and appear in the International Classification of Functioning, Disability and Health (WHO, 2001).

So what can occupational therapists in a clinic, hospital, or community setting do to help this population now? According to the nature of the U.S. medical system, occupational therapists typically see women who have already developed conditions related to pregnancy and are seeking curative treatment (often surgery). Educating those women and families to change habits and modify child care techniques may halt injury progression and may positively affect the way they approach future pregnancies and children. Using custom orthoses, patient education, strengthening, postural control, and activity adaptation can reduce the likelihood of developing nerve compression or De Quervain’s in light of physical and activity changes in lifestyle (Kaux et al., 2011). Recommending that new mothers use certain equipment (e.g., breastfeeding pillows, bath stands, correct use of baby carriers) may help prevent pain. Establishing an exercise program (e.g., UE weight training, safe core strengthening) for the pregnant mother based on her needs addresses the established benefits of exercise during pregnancy (Shivakumar et al., 2011) and the recommendation of the American College of Obstetricians and Gynecologists (2002) of 20 to 30 min of exercise per day during pregnancy.

On a macro level, educating HCPs, hospital management, and government legislators that occupational therapists have a role to play in promoting this population’s health will slowly change the perception of pregnancy as a medical condition versus a healthy, natural occurrence that can respond well to health promotion practices. Hosting workshops through women’s health or musculoskeletal centers and networking with local obstetrics–gynecology practices will help create change. Scheduling community lectures about tackling musculoskeletal challenges and providing suggestions from the occupational therapist’s perspective during the perinatal period can reach a larger audience and strengthen the promotive role of our profession. This area of occupational therapy has so much potential for growth.

Conclusion

Despite limited evidence for this research topic and occupational therapists’ role in the perinatal population in the literature, occupational therapists are clinically seeing musculoskeletal diagnoses during the perinatal period more and more. This warrants important research into and focus on this emerging market and further exploration toward improved value creation for the occupational therapist. Drawing from a broad range of sources has demonstrated the scope and versatility of occupational therapy as a profession and the ability of occupational therapists to provide a holistic approach to their clients. My hope is that this article can contribute to the growing body of evidence in the occupational therapy literature to meet the goal of AOTA’s (2017) Vision 2025.