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A C TA Obstetricia et Gynecologica
AOGS M A I N R E SE A RC H A R TI C LE
The efficacy of moderate-to-vigorous resistance exercise
during pregnancy: a randomized controlled trial
KAROLINA PETROV FIERIL1, ANNA GLANTZ2 & MONIKA FAGEVIK OLSEN1
1
Institute of Neuroscience and Physiology, University of Gothenburg, and 2Antenatal Care, Primary Health Care,
Gothenburg, Sweden
Key words
Exercise, pregnancy, public health,
randomized controlled trial
Correspondence
Karolina Petrov Fieril, N€
arh€
alsan,
Rehabmottagning, Olskroken, 416 65
Gothenburg, Sweden.
E-mail: karolina.fieril@vgregion.se
Conflict of interest
The authors have stated explicitly that there
are no conflicts of interest in connection with
this article.
Please cite this article as: Petrov Fieril K,
Glantz A, Fagevik Olsen M. The efficacy of
moderate-to-vigorous resistance exercise
during pregnancy: a randomized controlled
trial. Acta Obstet Gynecol Scand 2015; 94:
35–42.
Received: 14 April 2014
Accepted: 29 September 2014
DOI: 10.1111/aogs.12525
Abstract
Objectives. To assess the effect and safety of moderate-to-vigorous resistance
exercise during pregnancy. Design. Randomized controlled study. Setting. Two
antenatal clinics in Gothenburg, Sweden. Population. Ninety-two healthy pregnant women. Methods. The intervention was administered during gestational
weeks 14–25. The intervention group received supervised resistance exercise
twice a week, performed at an activity level equivalent to within moderate-tovigorous (n = 51). The control group received generalized exercise recommendation, a home-based training program and a telephone follow up (n = 41).
Main outcome measures. Health-related quality of life, physical strength, pain,
weight, blood pressure, functional status, activity level, and perinatal data.
Results. Functional status deteriorated during the intervention in both groups
and pain increased. Significant differences between the groups were obtained
only for birthweight. Newborns delivered by women who underwent resistance
exercise during pregnancy were significantly heavier than those born to control
women; 3561 (452) g vs. 3251 (437) g (p = 0.02), a difference that disappeared when adjustment was made for gestational age (p = 0.059). Both groups
showed normal health-related quality of life, blood pressure, and perinatal data.
Conclusions. These findings indicate that supervised, moderate-to-vigorous
resistance exercise does not jeopardize the health status of healthy pregnant
women or the fetus during pregnancy, but instead appears to be an appropriate
form of exercise in healthy pregnancy.
BP, blood pressure; DRI, disability rating index; GDM,
gestational diabetes mellitus; HRQoL, health-related quality of life; RCT,
randomized controlled trials; SF-36, Short Form-36 Health Survey.
Abbreviations:
Introduction
Maintaining a physically active lifestyle is associated with
many benefits, including lower risk of cardiovascular disease, diabetes, hypertension, some types of cancer, and
depression (1). Exercise is defined as a planned, structured, and repetitive subset of physical activity that
improves or maintains physical fitness, overall health or
well-being as an intended intermediate or final objective
(2). Pregnant, healthy women are recommended to do
30 min or more of light to moderate exercise a day on
most, if not all, days of the week (3,4). Exercise during
pregnancy is associated with reduced back pain (5),
improved health perception (6), and weight gain control
Key Message
Supervised regular, moderate-to-vigorous resistance
exercise has no adverse effect on childbirth outcome,
pain, or blood pressure. Further investigation into the
use of resistance exercise during pregnancy is needed.
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 35–42
35
Resistance exercise during pregnancy
(7). In the literature investigations have reported on the
effect of aerobic exercise when adopted in pregnancy.
Only a few randomized controlled trials (RCT) have,
however, examined the efficacy and safety of resistance
exercise during pregnancy (8–10). One study found resistance exercise performed with an elastic band effective in
improving glycaemic control in women with gestation
diabetes mellitus (GDM) (9). No adverse impact on the
delivery (10), or the newborn has been seen (8). Hence,
in their review Nascimento et al. (11) suggested adding
resistance exercise to the exercise recommendations.
Although the exercise recommendations do not provide
specific guidance for vigorous intensity exercise (3,4), Nascimento et al. (11) suggested that their results supported
the promotion of moderate-to-vigorous prenatal exercise.
Ruchat et al. (12) concluded that a walking program of
vigorous intensity is safe and beneficial to both the
mother and fetus, and also promotes decline in glucose
concentrations among women at risk of GDM (13). In a
prospective study Jukic et al. found an association
between first-trimester vigorous exercise and longer gestation, and reduced risk of preterm births (14). To the best
of our knowledge, no RCT has been conducted that studies prenatal resistance exercise at moderate-to-vigorous
intensity.
The aim of this study was to evaluate the health effect
and safety of moderate-to-vigorous intensity resistance
exercise when free weights are used by healthy women
during pregnancy, with regard to health-related quality of
life (HRQoL), pain location, physical strength, body
weight gain, blood pressure (BP), functional status, activity level, and childbirth outcomes.
Material and methods
Participants for this study were recruited from February
2006 through November 2006, and from September 2008
through April 2009, all from two antenatal clinics in
Gothenburg, Sweden. Background variables did not significantly differ in between the two study periods. The
participants were verbally informed about the study by
midwives or they received written information available
at the antenatal clinic. Those interested in participating
contacted the research coordinator. The criteria of inclusion were: (i) Pregnancy <14 weeks of gestation; (ii) single pregnancy; (iii) absence of medical or obstetric diseases; (iv) ability to understand verbal and written Swedish. Criteria of exclusion followed the recommendation regarding contraindications according to the American College of Obstetricians and Gynecologists (4). Approximately 1500 pregnant women had been registered at the antenatal clinics at that time (99% of Swedish women receiving combined obstetric and midwifery 36 K. Petrov Fieril et al. care have their deliveries in the public health system, via antenatal clinics) (15). Of 116 women willing to participate, 24 were excluded for either twin pregnancy or being ≥14 weeks of gestation. Hence, 92 women were included (Figure 1). The study was approved by the Regional Ethical Review Board at the University of Gothenburg (D No. 353-05) and registered in the Research and Development Center in Sweden (registration number VGFOUGSB-4388). Written informed consent for participation was obtained from each participant. The CONSORT guidelines were followed while conducting the study. The women were enrolled at gestational week 13, at which time the research coordinator (physiotherapist) met with each and provided them with general exercise recommendations and a home training program. Participants were randomly assigned to either the intervention group or the control group (allocation ratio 1:1). The research coordinator performed the randomization by using opaque sealed envelopes, which were randomly picked out before the meeting with each participant. All data were collected at a primary health care location by an investigator (physiotherapist) who was blinded to participant group status. The intervention group practised high-repetition, resistance training twice a week for 12 weeks (pregnancy weeks 14–25), performed using light barbells [1–10 lbs (0.45–4.5 kg)] and weight plates [2.5– 10 lbs (1.1–4.5 kg)], which was carried out while listening to music in a supervised (by the research coordinator) group exercise setting (16). The exercises were selfadjusted to each woman’s condition of pregnancy and performed at a self-estimated, moderate to vigorous intensity (17). Each session was 60 min long, including warm-up and wind-down. All major muscle groups were trained repeatedly (50–80 repetitions for each muscle group) during 3–5 min, including shorter breaks. The training was inspired by BODYPUMPTM (16) but adjusted to pregnant women: warm-up and relaxation periods were extended a few more minutes, squat jumps were exchanged for heel raises, the squats were less deep and the abdominal training was exchanged for pelvic-lift and static-abdominal training. All such training was performed with good form for trunk- and pelvic-floor muscle control and these were supervised by the research coordinator. Besides this training, additional exercises were recommended to the participants, including walking, bicycling, water-gymnastics, Pilates, yoga and resistance exercises. Compliance was defined as participation in at least two-thirds of all training sessions. Control group participants received general exercise recommendations during pregnancy and were informed of appropriate exercise and exercise frequency. Additionally, they were given written guidance and instruction on ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 35–42 K. Petrov Fieril et al. Resistance exercise during pregnancy Assessed for eligibility (n = 116) Excluded (n = 24) ♦ Not meeting inclusion criteria (n = 24) Enrollment Randomized (n = 92) Allocation Allocated to intervention group (n = 51) ♦ Received allocated intervention (n = 51) Allocated to control group (n = 41) ♦ Received allocated intervention (n = 41) Lost to follow up (n = 13) Lost to follow up (n = 7) Discontinued intervention (timeconstraints)(n = 5) Change of work (n = 2) Personal reasons (n = 1) Moving from town (= 1) Dislocated placenta (n = 1) Discomfort during exercise (n = 1) Pelvic girdle pain (n = 1) Miscarriage (n = 1) Follow up Not motivated (n = 3) Personal reasons (n = 2) Moving from town (n = 1) Miscarriage (n = 1) Analysis Analysed (n = 38) ♦ Excluded from analysis (n = 0) Analysed (n = 34) ♦ Excluded from analysis (n = 0) Figure 1. Flow diagram summarizing the study design. a general training program containing home exercises suitable for pregnancy, including pelvic-floor muscle training. They were offered a free visit to a physiotherapist if desired. Exercises were recommended to the control participants, including walking, bicycling, watergymnastics, Pilates, yoga and resistance exercises. In pregnancy week-18 the research coordinator contacted the controls by telephone for follow up. Before and after the intervention the participants filled in questionnaires and performed the following tests: HRQoL was measured using the Short Form-36 Health Survey (SF-36; Swedish Acute Version 1.0) (18) SF-36 comprises 36 items, 35 of which are arranged in eight physical and mental health scales, and one being a self report of health change. Scores may be obtained ranging from 0 to 100. Higher scores positively correlate with higher levels of functioning. The eight sub-scales are: (i) physical functioning; (ii) role, physical; (iii) bodily pain; (iv) general health; (v) vitality; (vi) social functioning; (vii) role, emotional; and (viii) mental health. Pain was measured using a graphic (drawings) depiction of body locations, upon which the participant would localize the area of pain. Scores were assigned to indicate the presence or absence of pain in each of 45 body areas (19). Five areas located to the lower back and pelvis were selected for analysis. Hand-grip isometric strength was defined as the peak, voluntary, hand-grip force applied using the Grippit electronic hand-grip strength detector (GrippitAB, Gothenburg, Sweden), administered in accordance with standard laboratory protocol (20). Grip strength correlates with upper extremity strength (21). Weight gain and BP were obtained from medical records at the perinatal clinic, Primary Health Care, Gothenburg, Sweden. Weight gain was measured in kilograms, wearing clothes but with no shoes. Functional status was measured by the Disability Rating Index (DRI) and recorded on a visual analogue scale, i.e. a self-estimation scale from 0 to 100, where 0 indicated no restricted activity and 100 indicated inability to perform the activity. The DRI includes 12 items that measure functions, including: dressing, outdoor walks, climbing stairs, sitting for a longer time, standing bent over a sink, carrying a bag, making bed, running, light physical activity, heavy physical activity, lifting heavy objects and participating in exercises/sports. During the intervention period all of the participants kept a structured diary of daily physical activity, according to the ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 35–42 37 Resistance exercise during pregnancy K. Petrov Fieril et al. Table 1. Baseline demographics and clinical characteristics; mean values  SD or n (%). Baseline demographics Maternal age, mean (SD) Education, years at school, mean (SD) Prepregnancy body mass index, mean (SD) Activity level pregnancy week 13 (min/day), mean (SD) Walking Moderate Vigorous Primipara, n (%) Marital status, n (%) Married/ cohabiting, n (%) Smoking, n (%) Taking snuff, n (%) Intervention group (n = 38) Control group (n = 34) p-value 30.8 (3.6) 30.6 (3.4) 0.77 15.4 (1.79) 16.3 (1.8) 0.07 The participants estimated the number of minutes per day that they had performed the different activities. Perinatal data, including birthweight, birth length, gestational age at time of delivery and cesarean section rates were obtained from the Sahlgrenska University Hospital’s perinatal records. Statistical analysis 22.6 (2.5) 23.0 (2.6) 0.50 52 11.7 1.1 28 47 18.3 1.2 28 0.68 0.12 0.89 0.52 (47) (14.8) (3.2) (74) 38 (100) 1 (2.5) 1 (2.5) (58) (20.7) (4.3) (82) 33 (97) – – 0.47 0.52 0.52 short form of International Physical Activity Questionnaire (22). Each activity was divided into “vigorous intensity”, “moderate intensity”, “walking” and “sedentary”. The sample size calculation was calculated on a difference in HRQoL measured by SF-36. To detect a clinically significant difference between groups with 80% power and at the 5% significance level, and a difference between groups of 10 units, 40 participants were needed in each group. Group-mean differences in physical strength, body mass index, BP, activity level, birthweight, birth length, and gestational age were analyzed by the Student’s t-test or chi-squared test using statistical software SPSS version 22.0 (IBM Corp, Armonk, NY, USA). Subgroup scores in SF-36 and DRI were analyzed using the Mann–Whitney U-test. Birthweights adjusted for gestational week were converted to Z-scores. A p-value <0.05 (two-tailed) was defined as significant. Only participants who fully completed the trial according to the protocol were considered compliant and analyzed. Ninety-two women met the inclusion criteria and were enrolled (Figure 1). No significant differences in background characteristics were found between the group of women who dropped out and those for whom complete Figure 2. Group differences in Quality of Life (SF-36) between gestational weeks 13 and 25, respectively, Intervention group (n = 38) and Control group (n = 34). Abbreviations: PF, Physical Functioning; RP, Role Physical; BP, Bodily Pain; GH, General Health; VT, Vitality; SF, Social Functioning; RE, Role Emotional; MH, Mental Health. 38 ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 35–42 K. Petrov Fieril et al. data were obtained, up to and including gestational week 25. Sixty percent of the women in the intervention group estimated their own resistance exercise as “vigorous” and 40% rated their exercise as “moderate” intensity. The mean attendance rate in the intervention group was 80% (67–100%). Results The group means for the intervention group and control group did not significantly differ on multiple variables, including: age, education, parity, pre-pregnancy body mass index, physical activity, marital status, and tobacco status (Table 1). HRQoL did not differ between the intervention group and controls (Figure 2), neither number of women with back pain nor those with pelvic pain (Table 2). Group-means scores for peak voluntary strength, weight gain, BP, and activity level did not differ significantly (Table 2). As shown in Figure 3, no significant differences were found between the groups in physical functioning, measured by the DRI. Birthweights were significantly higher in the intervention (x ̅I = 3561  452 g) compared with the control group (x ̅c = 3251  437 g; p = 0.02). However, when adjusted for gestational age, this difference did not remain (p = 0.059). The mean birth length was 50.7 (2.1) cm in the intervention group and 49.4 (2.6) in controls (p = 0.10), and gestational age was 280.1 (12.5) days in the intervention group and 276.7 (7.7) among controls (p = 0.16). There were no differences in cesarean section rates. In each group, five women had a cesarean section: 14% and 15% in the intervention group and the control group, respectively. Discussion Benefits of resistance exercise for adults are well-known (23), but in pregnancy women are recommended to proceed with caution, particularly when exercise is performed at moderate or vigorous levels (3,4). The present study indicates that supervised regular, moderate-to-vigorous resistance exercise performed twice a week does not adversely impact childbirth outcome, pain, or BP. However, it is important to note that physical and emotional status changes accompany pregnancy, including a decrease in functional status and an increase in pain, whether one does resistance exercise or not. The intervention did not have any significant impact on HRQoL. Previous studies were inconclusive. Barakat et al. reported improved health self-perception, a component of HRQoL, among previously sedentary pregnant women (6). However, other studies failed to show a significant increase in HRQoL among exercising, overweight/obese Resistance exercise during pregnancy Table 2. Pain, peak voluntary strength, weight, systolic blood pressure, diastolic blood pressure. Outcome Intervention group (n = 38) Control group (n = 34) Pain, n (%) Gw 13 12 (31%) 12 (36%) Gw 25 22 (58%) 21 (52%) Peak voluntary strength, mean (SD) Left hand Gw 13 311 (47) 309 (58) Gw 25 317 (52) 311 (55) Right hand Gw13 338 (46) 342 (58) Gw25 344 (54) 248 (67) Weight Gw13 66.5 (9.3) 65.0 (10.3) Gw25 72.7 (9.2) 70.5 (11.0) Systolic blood pressure Gw13 109 (18.8) 111 (10.5) Gw25 112 (8.8) 112 (9.7) Diastolic blood pressure Gw13 66.2 (8.3) 63.7 (7.7) Gw25 65.7 (8.2) 63.4 (7.8) Activity level Walking Gw13 52 (47) 47 (58) Gw25 118 (109) 79 (76) Moderate Gw13 11.7 (14.8) 18.3 (20.7) Gw25 15.8 (12.9) 16.8 (15.4) Vigorous Gw13 1.1 (3.2) 1.2 (4.3) Gw25 11.2 (26.9) 4.6 (7.1) Sedentary Gw13 316 (196) 366 (170) Gw25 372 (171) 384 (171) p-value CI 0.40 0.52 0.92 0.65 25.8 to 23.2 31.2 to 19.4 0.73 0.69 20.7 to 28.1 24.3 to 32.8 0.61 0.80 6.1 to 3.1 6.7 to 2.6 0.39 0.56 5.1 to 9.2 4.7 to 4.0 0.35 0.56 6.23 to 1.28 6.02 to 1.52 0.68 0.08 0.12 0.76 29.6 to 19.4 83.6 to 5.1 1.73 to 14.99 5.60 to 7.61 0.89 0.15 1.88 to 1.64 15.9 to 2.78 0.25 0.77 35.9 to 136.2 68.8 to 92.7 Mean values  SD and con ... 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