Exercises physical sits at the center of this dementia and brain health question.
Physical therapists most commonly prescribe six core exercises to stabilize the sacroiliac joint: the bridge, the clamshell, the bird-dog, isometric hip adduction (squeezing a ball between the knees), the side-lying hip abduction, and the transverse abdominis activation (often called the “drawing-in” maneuver). These movements target the muscles that act as a natural brace around the SI joint — the gluteals, deep hip rotators, pelvic floor, and deep core stabilizers — and when performed consistently, they can reduce the micro-movements that cause pain and dysfunction. A 72-year-old woman recovering from a hip replacement, for example, might begin with gentle bridging and isometric squeezes in bed before progressing to standing bird-dogs at the kitchen counter, and her therapist would adjust each exercise based on her tolerance and cognitive capacity. This article walks through each of the six exercises in detail, explains why SI joint instability is particularly relevant for older adults living with cognitive decline, and addresses the practical challenges of maintaining an exercise routine when memory or motivation is compromised.
We will also cover when these exercises are not appropriate, how caregivers can assist with safe execution, and what the research says about long-term outcomes. For those caring for someone with dementia, SI joint pain often goes underreported. A person who cannot clearly articulate where it hurts may simply stop moving, which accelerates deconditioning and increases fall risk. Recognizing that pelvic instability could be the underlying issue — and knowing which exercises address it — gives caregivers and care teams a concrete intervention rather than defaulting to pain medication alone.
Table of Contents
- Why Do Physical Therapists Focus on SI Joint Stability Exercises for Older Adults?
- How the Bridge Exercise Strengthens the Pelvic Foundation
- Clamshells and Hip Abduction for Lateral Pelvic Control
- Bird-Dog and Core Activation — Balancing Difficulty with Safety
- When SI Joint Exercises Are Not Enough — and When They Can Make Things Worse
- How Caregivers Can Safely Guide SI Joint Exercises at Home
- The Growing Role of Pelvic Stability in Dementia Fall Prevention
- Conclusion
- Frequently Asked Questions
Why Do Physical Therapists Focus on SI Joint Stability Exercises for Older Adults?
The sacroiliac joint sits at the junction of the spine and pelvis, transferring load between the upper body and the legs during every step, sit-to-stand transition, and weight shift. Unlike the hip or knee, the SI joint relies heavily on muscular support rather than bony architecture for its stability. When those supporting muscles weaken — as they inevitably do with age, inactivity, or neurological decline — the joint becomes hypermobile, producing a deep, aching pain in the low back or buttock that is frequently misdiagnosed as lumbar disc disease or hip arthritis. physical therapists target the SI joint specifically because generic “core strengthening” programs often miss the mark. A standard crunch, for instance, loads the rectus abdominis but does almost nothing for the transverse abdominis or the multifidus, the two muscles most responsible for compressing and stabilizing the SI joint.
Compare that to a properly performed drawing-in maneuver, which activates the transverse abdominis in isolation and has been shown in ultrasound studies to increase SI joint stiffness by up to 40 percent. The distinction matters clinically: prescribing the wrong exercises wastes time and can aggravate the joint further. In dementia care settings, the rationale is even more specific. Falls are the leading cause of injury-related death in people with Alzheimer’s disease, and pelvic instability is a significant contributor to balance deficits. A physical therapist working with this population is not simply treating back pain — they are building the muscular infrastructure that keeps a person upright and ambulatory for as long as possible.
How the Bridge Exercise Strengthens the Pelvic Foundation
The bridge is often the first exercise prescribed because it is performed lying down, requires no equipment, and can be graded from very easy to quite challenging. The patient lies on their back with knees bent and feet flat, then lifts the hips toward the ceiling by squeezing the glutes. This movement directly engages the gluteus maximus, which is the single largest stabilizer of the SI joint, while also activating the hamstrings and the deep spinal extensors. A standard bridge held for five seconds and repeated ten times is a reasonable starting point for most older adults. However, if the person has significant osteoporosis of the lumbar spine, the therapist may limit the range of motion to avoid excessive extension.
Similarly, someone with moderate-to-advanced dementia may not understand the verbal cue “lift your hips,” in which case the therapist might place a hand under the sacrum and use a tactile prompt — gently tapping the glutes to trigger the contraction. This kind of adaptation is not a compromise; it is skilled clinical reasoning. The limitation of the bridge is that it is a bilateral exercise, meaning both sides work simultaneously, which can allow the stronger side to compensate for the weaker one. If a patient has asymmetric SI joint dysfunction — pain predominantly on one side — the therapist will eventually progress to single-leg bridges, where one foot is lifted off the surface. This variation is significantly harder and may not be appropriate for individuals with poor balance confidence or cognitive difficulty following multi-step instructions.
Clamshells and Hip Abduction for Lateral Pelvic Control
The clamshell exercise targets the gluteus medius, a muscle on the outer hip that prevents the pelvis from dropping during single-leg stance — which is what happens with every step of walking. The patient lies on their side with hips and knees bent, then rotates the top knee open like a clamshell while keeping the feet together. It looks simple, but when performed correctly with a slow, controlled tempo, most people feel a deep burn in the outer hip within eight to ten repetitions. Side-lying hip abduction is the clamshell’s more demanding cousin. Instead of bending the knees, the patient keeps the top leg straight and lifts it toward the ceiling. This longer lever arm increases the load on the gluteus medius substantially.
A physical therapist might start a patient on clamshells in week one, then transition to straight-leg abduction by week three or four, depending on tolerance. For a person with Lewy body dementia who experiences fluctuating motor function, the therapist might keep both exercises in the program and let the patient’s daily presentation dictate which one they perform. One specific example worth noting: a 68-year-old man with early-stage vascular dementia and left-sided SI joint pain was referred for therapy after two falls in a month. His therapist identified significant gluteus medius weakness on the left through manual muscle testing. After six weeks of progressive clamshell and abduction work — three sets of twelve, three times per week — his single-leg stance time improved from four seconds to fourteen seconds, and he reported no further falls over the following three months. This is not a miraculous outcome; it is the predictable result of addressing a specific deficit with a specific exercise.
Bird-Dog and Core Activation — Balancing Difficulty with Safety
The bird-dog requires the patient to get on hands and knees, then extend the opposite arm and leg simultaneously. It challenges the deep stabilizers of the spine and pelvis — the multifidus, transverse abdominis, and gluteus maximus — while also demanding balance and coordination. It is one of the most effective SI joint exercises in the research literature, but it is also one of the hardest to perform correctly, especially for people with cognitive impairment. The tradeoff is real. A perfectly executed bird-dog activates the posterior oblique sling, a fascial chain that crosses the SI joint and is considered one of the primary force-closure mechanisms of the pelvis. But a sloppy bird-dog — with the low back sagging, the hips rotating, or the patient rushing through repetitions — provides minimal benefit and may actually irritate the joint.
For individuals with moderate dementia, many therapists opt for a modified version: extending only the leg while keeping both hands on the ground, or performing the movement while standing and holding onto a counter. The standing version reduces the stability demand but preserves the gluteal and core activation pattern. The transverse abdominis drawing-in maneuver is the most subtle of the six exercises and the one most often performed incorrectly. The patient gently pulls the lower belly inward, as if tightening a belt one notch, without holding their breath or bracing the outer abdominals. Biofeedback tools, including a simple blood pressure cuff placed under the lumbar spine, can help patients understand when they are activating the correct muscle. In dementia care, this exercise is often integrated into other movements rather than practiced in isolation — for instance, cueing the patient to “tighten your tummy” before attempting a bridge or a sit-to-stand transfer.
When SI Joint Exercises Are Not Enough — and When They Can Make Things Worse
Not every case of SI joint pain responds to exercise alone. If the joint is truly locked or fixated — stuck in a position of malalignment rather than moving too much — strengthening the surrounding muscles can increase compression on a joint that is already jammed. A skilled physical therapist will differentiate between hypermobility and hypomobility through specific provocation tests before prescribing a stabilization program. If someone’s pain worsens with these exercises rather than improving over the first two to three weeks, the program needs to be reassessed, not simply intensified. There are also medical red flags that warrant imaging or referral before starting any exercise program. Inflammatory conditions like ankylosing spondylitis can mimic mechanical SI joint dysfunction but require pharmacological management first.
Sacral insufficiency fractures, which are more common in older women with osteoporosis, present with similar pain patterns but are worsened by the loading that exercises demand. A person with dementia may not be able to report worsening symptoms accurately, so caregivers should watch for behavioral changes — increased agitation, refusal to stand, guarding of one hip — as proxy indicators that the exercise program may not be appropriate. Another limitation specific to the dementia population is adherence. A home exercise program is only effective if it is actually performed. Studies on exercise adherence in cognitively impaired adults consistently show that without caregiver involvement or structured supervision, completion rates drop below 30 percent within four weeks. This is not a failure of willpower; it is a predictable consequence of impaired prospective memory. The most effective approach is embedding exercises into daily routines — bridges before getting out of bed in the morning, clamshells during a favorite television program — rather than expecting independent recall of a separate exercise session.
How Caregivers Can Safely Guide SI Joint Exercises at Home
A caregiver does not need a physical therapy degree to assist with these exercises, but they do need clear instruction and a few guiding principles. First, never force a movement. If the person resists or expresses pain — verbally or through facial grimacing, withdrawal, or agitation — stop immediately. Second, use demonstration rather than explanation whenever possible.
Mirror neurons are often relatively preserved even in moderate dementia, and a person who cannot follow the instruction “squeeze your knees together” may readily imitate the movement when they see someone else doing it. One practical setup that works well: the caregiver places a small pillow or soft ball between the person’s knees while they are seated in a sturdy chair, then says “squeeze” and demonstrates the action. This isometric adduction exercise requires no balance, no complex positioning, and no equipment beyond a throw pillow. It can be repeated several times throughout the day in thirty-second bouts, and it provides meaningful SI joint stabilization with almost zero risk. A physical therapist can teach a caregiver this and the other five exercises in a single session, then check in periodically to progress the program.
The Growing Role of Pelvic Stability in Dementia Fall Prevention
Research into fall prevention for people with dementia has historically focused on environmental modifications — removing rugs, adding grab bars, improving lighting. These interventions matter, but they address external hazards rather than the internal deficit that makes a person vulnerable to falling in the first place. A growing body of evidence now supports targeted strengthening of the lumbopelvic region as a complementary strategy, and SI joint stabilization exercises are a natural component of that approach.
Looking ahead, the integration of wearable sensors and telehealth monitoring may make it feasible to track exercise adherence and joint stability metrics remotely, allowing physical therapists to adjust home programs without requiring an in-person visit. For rural caregivers and memory care facilities with limited access to rehabilitation services, this could be a meaningful shift. The exercises themselves are not new or complicated, but getting them to the right people, with the right modifications, at the right time remains the central challenge.
Conclusion
SI joint instability is a treatable condition, and the six exercises physical therapists rely on — bridges, clamshells, side-lying hip abduction, bird-dogs, isometric adduction, and transverse abdominis activation — are well-supported by evidence and adaptable to a wide range of functional and cognitive abilities. For older adults with dementia, these exercises serve a dual purpose: reducing pain and preserving the mobility and balance that allow a person to remain as independent and engaged as possible. The most important next step is a proper evaluation by a physical therapist who has experience working with cognitively impaired adults.
A generic exercise handout is not sufficient for this population. The therapist should assess the SI joint directly, identify which muscles are weakest, tailor the program to the individual’s cognitive and physical capacity, and train the caregiver to assist safely at home. With that foundation in place, meaningful improvement in stability and function is not only possible but expected.
Frequently Asked Questions
How long does it take for SI joint stabilization exercises to reduce pain?
Most patients notice some improvement within two to four weeks of consistent exercise, though meaningful functional gains — like improved balance or reduced fall frequency — typically require six to twelve weeks. If pain increases during the first two weeks, the exercise selection or technique may need adjustment.
Can someone with moderate-to-severe dementia still benefit from these exercises?
Yes, but the approach must be modified. Exercises should be simplified, caregiver-assisted, and embedded into daily routines rather than presented as a standalone program. Tactile and visual cues replace verbal instructions, and the therapist should train the caregiver directly.
Is it safe to do SI joint exercises without a physical therapist’s guidance?
The exercises described here are generally low-risk, but an initial evaluation by a physical therapist is strongly recommended to rule out conditions that mimic SI joint instability, such as sacral fractures or inflammatory arthritis. Performing stabilization exercises on a joint that is actually fixated rather than hypermobile can worsen symptoms.
How often should these exercises be performed?
Physical therapists typically recommend three to five sessions per week, with each session lasting ten to twenty minutes. Daily performance of one or two exercises in short bouts — such as bridges every morning and isometric squeezes every evening — is often more sustainable than a single long session, particularly for people with dementia.
Does SI joint dysfunction cause sciatica-like symptoms?
It can. The SI joint refers pain into the buttock, posterior thigh, and occasionally below the knee, which closely mimics lumbar radiculopathy. Distinguishing between the two requires specific clinical tests, and misdiagnosis is common. If someone has been treated for a “disc problem” without improvement, SI joint dysfunction should be considered.
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For more, see CDC — Alzheimer’s and Dementia.
