The PGM Method - Activating the Core, Targeted Strengthening and Stretching for the Pelvic Girdle

Original Editor - Deborah Riczo, Wanda van Niekerk
Top Contributors - Wanda van Niekerk, Tarina van der Stockt, Kim Jackson, Jess Bell, Vidya Acharya and Lucinda hampton

Introduction

Activating the deep core muscles and addressing specific muscles that are weak and tight are important components of the Pelvic Girdle Musculoskeletal Method^sm, or PGM Method^sm. This is in addition to, and after the muscles of the pelvic girdle have been balanced using PGM exercises in a very specific algorithm.

Therapeutic exercises have beneficial effects on pelvic girdle pain and dysfunction. They can improve performance of the pelvic floor muscles, back flexors and extensors, and hip extensors. Exercise may also reduce the intensity of pain, as well as the level of disability experienced. 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. Exercise should also be used as an intervention for pelvic girdle pain in the antepartum population, according to the clinical practice guidelines for this population. Rehabilitation exercises may also prevent future episodes of pelvic girdle pain during pregnancy and in subsequent pregnancies. However, in pregnancy, it has been found that early intervention is important and "instiling the belief that it can improve" can enhance long-term outcomes.

Core Activation

The deep or inner core muscles are:

• Transversus abdominis
• Pelvic Floor
• Diaphragm
• Multifidus

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:

• Stable and symmetric position (static position), pelvis neutral
• Asymmetrical positions in a static position (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)

Activating the deep core

• Start with a diaphragmatic breath in the chosen static position
  • INHALE:
    • Abdominal muscles should soften
    • Rib cage expanding with the inhale
    • Pelvic floor muscles relax and lengthen
  • EXHALE through pursed lips, with a hissing sound, or other noise to activate the glottis, tension the pelvic floor (see "Other clinical notes, bullet 2, below if there is pain), and transversus abdominus.

• Connect cues for engaging pelvic floor and transversus abdominis during EXHALE
  • 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

Other clinical notes:

1. Blowing out through pursed lips or making a "hissing" sound improves pelvic floor contraction. Exhaling pattern can be a clinical decision based on level of core weakness
2. If the patient’s pain is increasing with a pelvic floor contraction, this may indicate possible hypertonic pelvic floor muscles. In this case, do not include the pelvic floor contraction with the exhale, but have the patient focus on the relaxation of the pelvic floor muscles with the inhalation, envisioning lengthening or other imagery
3. Aim to repeat this core activation pattern 10 times in a static position. Repeat this core activation in sets of approximately 10 in other static positions so the muscles are challenged with varying effects of gravity, ie. supine, prone, standing, 4 point, kneeling
4. The number of repetitions and starting static positions chosen are based on clinical reasoning and decision-making, keeping in mind that the muscles need to be worked to fatigue in order to strengthen, and with respect to patient tolerance
5. The inner core muscles work automatically, but it has been shown that with pelvic girdle dysfunction and other injuries that these muscles can become inhibited. Communication to the patient that the goal is to get these muscles to work automatically in a reasonable timeframe.

Targeted Stretching

Muscle flexibility is an important part of the assessment in patients with pelvic girdle pain and dysfunction. Patients are often tighter on the side of pain and it can be beneficial to provide them with specific unilateral stretches at the level they can tolerate. It is also recommended that you ask the patient if they perceive one side to be tighter than the other rather than only relying on objective assessment.

Some of the muscles that may be tight or shortened include:

• Hip extensors
• Hip flexors
• Hip rotators
• Hip adductors
• Hip abductors
• Quadriceps
• Hamstrings
• Lumbar rotators
• Latissimus Dorsi

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

Targeted Strengthening

The painful side in patients with pelvic girdle dysfunction often shows signs of weakness and decreased balancing abilities. The algorithm of exercises described in the Pelvic Girdle Musculoskeletal Method is relevant strengthening exercises in patients with pelvic girdle dysfunction, especially when progressing with Theraband and bridging as in Exercise 2b, 2c of the PGM Method.  It is important to include the core activation principles with any targeted strengthening exercises in order to engage the core during these exercises.  If a patient perceives one side is weaker while performing the exercise, ie. feels more difficult, then this is a good indication that the exercise/muscle group needs to be included in the exercise prescription.

Below are some examples of exercises that could be considered in patients with pelvic girdle dysfunction if there are signs of weakness in specific muscle groups.