Pelvic girdle pain (PGP) and pelvic floor dysfunction (PFD)

Despite being fit, healthy and an experienced Pilates instructor, having a baby challenged my body much more than I had expected. A tough delivery led to me being unable to walk unassisted and unable to contain my bladder. I struggled to recover normal function and have been inspired to learn more about these all too common conditions. Thanks particularly to Kath Banks for her Pilates instruction and assistance with my recovery. I’m 95% better!

Many pre and post-natal women do experience debilitating symptoms of pelvic girdle pain (PGP) and pelvic floor dysfunction (PFD). PGP is pain anywhere in the pelvis and is commonly associated with the sacroiliac or pubic symphysis joints. PFD is an umbrella term used to describe a variety of continence issues.

Three important considerations for the prevention of and recovery from these conditions are as follows:

1. Standing alignment and gait pattern

Pelvic bones do move.

Muscles surrounding the pelvis impact the alignment of the sacrum and the pelvic bones that it articulates with. Muscles also play an important role in aligning the pelvis relative to the rest of the skeleton whilst standing and walking.

The musculature around the pelvis needs to be both strong and supple enough so that the skeleton is held stable but not pulled out of alignment when standing and walking.

The uterus attaches to the inner surface of the sacrum. As the foetus grows, the weight of the uterus can pull forward on the sacrum and pull it away from the articulating ilium or cause the pelvis to sway forwards. In both cases, there is shearing pressure on pelvic joints and downward pressure on the pelvic floor whilst standing and walking.

Programming to support standing pelvic alignment includes:

  • Standing arm series using the Cadillac arm springs or push through bar, adding variations with squats, rises and, depending on the client, single leg and/or single arm.
  • Wunda chair standing leg press and standing extended leg press are fantastic for currently stable clients.

Focus on ideal alignment, femur over ankle, neutral pelvis on femur and neutral ribs on pelvis.

Focus on gluteal activation to prevent sway pelvis and lateral hip sag.

2. Pelvic floor function

The pelvic floor (PF) supports the pelvic organs internally and stabilizes the pelvic bones from within. We need somatic muscle training for awareness of front, mid and back PF, and also for superficial and deep PF. Post delivery, women need to increase PF strength and endurance. Equally important is learning to actively release and relax PF, which is essential for voiding, childbirth and restoring PF to normal function.

Learning how to eccentrically contract PF is crucial to developing normal length and tone in the pelvic floor. A PF that only shortens and lifts will eventually become too short and tight, thereby decreasing its ability to function.

Eccentric PF muscle contractions are very much the domain of the Pilates instructor. Ensuring a client works with principles of neutral pelvis, neutral lumbar spine, hip disassociation and then moves into deep hip flexion causes the PF to contract eccentrically as the sacrum and coccyx are elongated away from pubic symphysis. This allows the sacrum to nestle back in position between the ilium and ensures the pelvic floor is at optimal length to contract as and when needed to prevent incontinence.

Programming that facilitates eccentric pelvic floor contraction without necessarily making PF a focus for the client includes:

  • reformer and wunda chair footwork
  • reformer leg strap work series – knee bends, frogs, open/close, circles
  • quadruped neutral rock backs
  • knee stretch in neutral
  • squats into deep hip flexion (depending on the clients ROM) and with neutral lumbar spine.

3. Gluteal function

The gluteal muscles are responsible for stabilising the pelvis via its posterior and lateral surfaces.

Like the uterus, gluteus maximus also attaches to the sacrum, (posterior attachment) surface. Strengthening and restoring gluteus maximus to normal function will stabilise the position of the sacrum back in line with the iliums, help to maintain PF at optimal length and assist with maintaining optimal standing pelvic alignment. This is particularly important during pregnancy to counter balance the forward pull weight of the growing belly

Programming to increase the strength of gluteus maximus:

  • prone glute work (in post-natal training)
  • neutral bridge hover, progressing with heel lifts, press up, let lifts
    quadruped bent knee lift
  • squats in all of their variations for all women including during pregnancy. To assist with glute max activation, ensure knees stay over heels and pelvis moves backwards into deep hip flexion with neutral lumbar spine.

Once optimal pelvic bone and standing alignment are achieved we need to consider the gait cycle. If glute med and min are weak and dysfunctional, then every step taken adds further downward pressure onto PF and jars the joints of the pelvis causing shearing, instability and ultimately pain.

Programming to increase the strength of glute minimus and medius:

  • side lying hip abduction bent leg, progress to straight legs
  • quadruped single leg glides with focus on the supporting leg
  • neutral scooter, with support leg as focus
  • standing single leg transfers with clear and strong lateral hip support
  • skater prep and variations of skater (depending on the clients’ condition and ability).

Conditions such as PFD and PGP are considered fairly normal results of pregnancy and delivery and are increasingly prevalent in clients. It is important that Pilates instructors address these areas of imbalance to best assist women through this massive physical transformation.

The body is a complex web and these points are in no way the only things to consider when teaching women with PGP and PFD. They are simply parts of the puzzle to consider when working with pre and postnatal women to help guide them into pain free functional movement.

By addressing PGP and PFD as symptoms of a poorly aligned skeleton within deconditioned supporting musculature, it is easy to see how, as teachers of movement, Pilates instructors can have a huge impact on how a woman experiences pregnancy, delivery and recovery.

Following are details of useful books, websites, and blogs:

The Female Pelvis, Anatomy and Exercises
Blandine Calais-Germaine and Nuria Vives Pares

Preparing for a gentle Birth, The Pelvis in Pregnancy
Blandine Calais-Germaine

The Bathroom Key, Put an End to Incontinence
Kathryn Kassai and Kim Perelli

Internet:

Diane Lee & Associates Physiotherapy: www.dianelee.ca

Britt Stug senior researcher, PT, supervisor PhD
Oslo University Hospital: Has published numerous articles relating to PGP

Katy Bowman: Katy Says “Alignment Matters” blog about alignment
PIA Australia – Pelvic Instability Australia has a fantastic free e-book on managing day-to-day activities with PGP, suitable to refer clients with PGP to.

Sophie Jeffries
Member
Pilates Alliance Australia

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