Alignment and the high, tight pelvic floor – it sounds like the start of a kids fairy tale. And maybe it is! Can a high, tight pelvic floor have a happily ever after? Could alignment be a knight in shining armor for the pelvic floor? My short answer is: yes! For the long answer keep reading….

A physical therapist specializing in pelvic health sent me a question related to alignment: How does the posture correction you suggest address a ‘shortened’ or high, tight pelvic floor?

My response: Great question! One of the notes I like to hit over and over and over again is the critical role of alignment to the function of the pelvic floor. Studies have shown improved resting activation of the pelvic floor when postural alignment moved more and more toward neutral. In my book, neutral has to do with aligning the rib cage over the pelvis. This ribs over pelvis position optimizes the interaction of the diaphragm and pelvic floor, promoting their pistoning action (down on inhale, up on exhale) which balances the intra-abdominal pressure (IAP) that insures lumbar and pelvic stability. This dynamic quality of rising and lowering with the respiratory cycle is lacking for a high, tight or shortened pelvic floor. Re-establishing the relationship between the diaphragm and pelvic floor helps to restore the ebb and flow movement of the pelvic floor. Getting the rib cage (where the diaphragm lives) over the pelvis (where the pelvic floor lives) helps to optimize this restorative interaction.

In addition, one of the concepts I have learned along the way from my pediatric teaching partner, Shelley Mannell, is the concept of dynamic holding as it relates to spastic muscles.  For some of the kids (with motor challenges) spasticity is both their enemy and their compensation. Their bodies and brains learn how to use the spasticity to stay up against gravity via what is known as dynamic holding. Spasticity has the appearance of shortened muscle and some of it is true length change. However, when they get botox injections, that dynamic holding component is eliminated and you see movement return and a relative improvement in “length”. We have seen dramatic changes in kids with spasticity when they tap into the pistoning relationship between the diaphragm and pelvic floor in alignment. It allows them to reduce their reliance on the spasticity to support upright posture and use properly sequenced muscle activation instead. The dynamic holding component reduces and we see what is left in terms of a true length issue.

This dynamic holding concept has helped explain to me why folks with high tight pelvic floors respond well to re-establishing the relationship between the diaphragm and pelvic floor which is optimized through neutral alignment. Is their shortened state true shortening or is it hyper vigilance against chronic overuse of abs? Is dynamic holding of the pelvic floor the bodies compensation instead of using a more effective strategy for postural support? Is it truly short or is it just functioning in that way?

I have found that I can address all of these clinical questions by linking the diaphragm action to the pelvic floor in optimized alignment to help patients learn to lower and relax the pelvic floor on inhale. If there is any emotional or ANS contributions to the high, tight state, then some focus on deep breathing can help to address that “upstream” contribution as well. Using pelvic floor lowering on inhale as the first cue also helps to avoid feeding into any overuse issues. In addition, the diaphragm and pelvic floor contribute to the IAP postural stability system which reduces the need to substitute the overuse of abs for central stability which can lead to over recruitment of the pelvic floor. Balance can be restored.

Or is it a chicken and egg thing. If they are in a chronically tucked under bum alignment, pulling sacrum toward the front, they may have created true adaptive shortening of the pelvic floor over time. Gradually addressing this alignment of the sacrum and pelvis would be necessary to promote adaptive lengthening of the pelvic floor. However, something to consider when assessing if it is the chicken or the egg – if it is truly shortened due to adaption vs dynamic holding I should not be able to get the sacrum to follow the pelvis as I untuck the bum to promote a more neutral tilt without increasing pain.

My goal is to optimize alignment in order to maximize the powerful relationship between the diaphragm and pelvic floor. If it is a combo of a truly shortened PF (which poor alignment would feed into), and faulty pelvic floor recruitment strategies (which poor alignment also feeds into) or neurologic/ANS strategies (which poor alignment actually feeds into…but that is a whole other blog)…then addressing that holistically with attention to the best alignment you can achieve, I propose is a viable clinical path.

And they all lived happily ever after……

Sapsford RR, Richardson CA, Maher CF, Hodges PW. Pelvic floor muscle activity in different sitting postures in continent and incontinent women. Arch Phys Med Rehabil. 2008;89(9):1741-1747