Pelvic Girdle Dysfunction Interventions: Core Activation, Targeted Strengthening and Stretching

Original Editor - Deborah Riczo

Top Contributors - Wanda van Niekerk, Kim Jackson and Jess Bell  

Introduction

Therapeutic exercises have beneficial effects on pelvic girdle pain and dysfunction and may reduce the intensity of pain, as well as the level of disability experienced.[1] For these exercises to have a beneficial effect they need to be meaningful to the patient, relevant for daily activities and individualised according to the patient's profile and abilities.[2] Guidance and supervision by a professional are also necessary to secure performance and quality.[2] Rehabilitation exercises may also prevent future episodes of pelvic girdle pain during pregnancy and in subsequent pregnancies.[3] It is also recommended that clinicians should consider the use of therapeutic exercise in the antepartum population with pelvic girdle pain.[4]

Core Activation

The deep or inner core muscles are:

These are the targeted muscles when the core is being activated. It is recommended to start with core activation exercises in a static and safe position and from there on one can progress. The progression of core stability exercises can be as follow[5]:

  • Starting of in a stable and symmetric position (static position)
  • Progressing to asymmetrical positions (still in a static position and adding movement of the extremities)
  • Mobility (adding a roller or ball under the trunk)
  • Agility (moving the trunk in space, balancing activities, lunges and dynamic balancing activities)

Activation of deep core

  • Start of with diaphragmatic breathing
    • Belly muscles should soften within the inhale
    • Rib cage expanding with inhale
    • Exhale through pursed lips
  • Engaging pelvic floor and transversus abdominis
    • On the exhale of the diaphragmatic breathing, engage the pelvic floor and transversus abdominis
    • Various connect cues that may help the patient with this are:
    • Transversus abdominis
      • imagine a line that connects the inside of the two pelvic bones (front of the hips). Think about connecting, or drawing the muscle along this line as if closing two book covers
      • imagine that you are pulling on a pair of tight jeans and flattening the lower abdomen to be able to pull up the zipper
    • Pelvic floor
      • visualize squeezing/closing of the urethra - as if to stop the flow of urine
      • visualize or squeeze/close the anus - as if to stop flatulence
  • Static core positions.png
    Blowing out through pursed lips or making a "hissing" sound improves pelvic floor contraction[5]
  • If the patient’s pain is increasing with pelvic floor contraction, this may indicate possible hypertonic pelvic floor muscles, leave this part out then[5]
  • Aim to repeat this core activation pattern 10 times in a position and do it in various positions, such as supine, prone, standing, 4 point kneeling
  • The amount of repetitions and in which positions you would start your patient of will be based on clinical reasoning and decision-making, keeping in mind that the muscles need to be worked to fatigue in order to strengthen[5]
  • The inner core muscles should be working automatically, but it has been shown that with pelvic girdle dysfunction and other injuries that these muscles do become inhibited[9]

Examples of core activation in different positions:

Targeted Stretching

Part of the assessment in patients with pelvic girdle pain and dysfunction is to include investigations to assess for any specific muscle tightness or shortening. Some of the structures that may be tight or shortened include:

For a quick recap of the anatomy of the pelvic girdle have a look at this page: Anatomy of the Pelvic Girdle

Patients are often tighter on the side of pain and it may be valuable to provide them with specific unilateral stretches. It is also recommended that you ask if the patient perceives one side to be tighter than the other.[5]

Examples of Stretches of Pelvic Girdle Muscles

Hip Extensors

Hip Rotators

Hip Flexors

Hip Adductors

Hip Abductors

Quadriceps

Hamstrings

Latisimus Dorsi

Targeted Strengthening

The painful side in patients with pelvic girdle dysfunction usually also shows signs of weakness and decreased balancing abilities.[5] The algorithm of exercises described in the Pelvic Girdle Musculoskeletal Method are relevant strengthening exercises in patients with pelvic girdle dysfunction. It is is important to include the core activation exercises with any targeted stretching exercises as well.[5] Below are some examples of exercises that could be considered in patients with pelvic girdle dysfunction if there are signs of weakness in specific muscles.

Gluteus medius strengthening

Hip Rotation

Functional exercise

[37]

References

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  2. 2.0 2.1 Stuge B. Evidence of stabilizing exercises for low back-and pelvic girdle pain–a critical review. Brazilian journal of physical therapy. 2019 Mar 1;23(2):181-6.
  3. Bogaert J, Stack M, Partington S, Marceca J, Tremback-Ball A. The effects of stabilization exercise on low back pain and pelvic girdle pain in pregnant women. Annals of Physical and Rehabilitation Medicine. 2018 Jul 1;61:e157-8.
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