Effect of Posture on Pelvic Floor

Introduction[edit | edit source]

Posture is simply the position our bodies adopt in response to the effects of gravity. It is the way we hold ourselves during the day in sitting, standing or even lying down position.

A 'Good' posture allows us to move with ease, causing our bodies the least amount of strain and damage.

The spine has four natural curves which help to distribute mechanical stress as body moves.

  • the cervical and lumbar curves are lordotic
  • the thoracic and sacral curves are kyphotic

With the advancement in technology and increase in screen time prolonged sitting with slumped posture can cause imbalance in the muscles. Studies have shown that pelvic floor muscle asymmetry is related to lumbopelvic complex malalignment.

The pelvic floor forms the base of the pelvis . They are the only transverse load-bearing muscle group in the body which provides antigravity support. It also supports the abdomino-pelvic organs such as the bladder, uterus and the rectum and provides lumbo-pelvic stability.

The pelvic floor is a part of the deep core system of the body which mainly comprises of the diaphragm, transverse abdominis, multifidus and the pelvic floor .These muscles function as a unit working synergistically to influence posture through intra-abdominal pressure regulation and thoracolumbar fascial tension.

The PFM contraction results in both:

  • cephalad movement and
  • anterior translation of of the pelvic floor which generates a closure force at the vaginal and subsequently the urethral lumen

Posture and Pelvic Floor[edit | edit source]

The whole body works better when it's in alignment (good posture) and this in turn optimizes pelvic floor muscle activity. The postures we operate in for most of the day plays a major impact on our pelvic floor .For example standing for extended periods is tiring so in order to reduce fatigue one tends to lock their knees back immediately causing a degree of pelvic tilt. On the other hand, most people especially these days with prolonged sitting habitually adopt lumbo-pelvic flexion posture switching off their deep core system. [1]Studies have shown that prolonged sitting posture causes muscle imbalance and leads to anterior pelvic tilt.

Poor Posture[edit | edit source]

Bad_posture

Sitting or standing with poor posture puts excessive pressure on abdominal and pelvic organs and strains the muscles and connective tissues that surround the joints. This can cause pelvic organ prolapse.[2] Poor posture can also affect women with already existing pelvic organ prolapse, incontinence(bladder and /bowel), with pelvic floor weakness after childbirth or with pelvic pain.

Deviation in the spinal curvatures especially loss of lumbar lordosis may exert high pressure on the pelvic supportive tissue and appears to be a significant risk factor in the development of pelvic organ prolapse.[3]Excessive thoracic kyphosis , may be a contributing factor in some women for pelvic organ prolapse. Thus poor posture can increase the load on the pelvic floor and worsen pelvic floor problems.

Effect of postural changes on Pelvic Floor[edit | edit source]

The pelvic floor muscles extend from the pubic symphysis anteriorly to the coccyx posteriorly. So let us imagine the pelvic floor to be a piece of fabric extending from the front to back. In an Anterior Pelvic tilt position, the muscles are taut and supple while in a Posterior tilt position, it is baggy and weak. The contractility of the Pelvic Floor Muscles may be altered with postural changes due to alterations in the length of the PFM fibers . Creating a hyper- or hypo lordosis distorts the PFMs by changing the orientation of their attachments to the sacrum, coccyx, pubic symphysis and ligamentous structures.

An anterior pelvic tilt (hyper-lordosis) causes a posterior rotation of the coccyx relative to the the pubic bones thereby producing a stretch on the PFMs and hence lengthening the muscle fibers .The posterior pelvic tilt (hypo-lordosis) causes an anterior rotation of the coccyx and thus creates a shortening of the muscle fibers. Both of these distortions decrease the ability of the PFMs to generate the maximum contractility due to the length tension properties of the muscle.[4]

((https://youtu.be/hcTEUKp7zsY))

Anterior Pelvic Tilt[edit | edit source]

[[1]]

With anteriorly tipped pelvis, the organs must be supported by the abdominal walls, displacing the effort of the supporting upper body from bones and the tight web of ligaments and muscles at the pelvic floor to less-suitable abdominal muscles and fascia often observable as a sagging or distention of the belly or sides of the abdomen.

Anterior pelvic tilt can sometimes start developing in Pregnancy and remain into Post Natal period and way beyond 'turns-off' the optimal functioning of the pelvic floor muscles .It can also prevent loosing of belly fat. In this posture, the chin would be pushing forward, shoulder and chest rounded constricting the ribcage making breathing difficult and may even cause indigestion. The abdominals and glutes remain slack hollowing the back, tilting pelvis forward .In this case we can refer to it as lower crossed syndrome. This can further cause backache ,strained abdominals and excess pressure on bladder. The knees if pushed back might strain the joints and push pelvis more forward. Weight on the inner borders strains arches of the feet and claves causing leg aches.

[[2]]


Excessive anterior pelvic tilt can be caused by:

  • seated jobs
  • faulty abdominal training
  • poor muscle imbalance
  • poor posture and
  • pregnancy


Problems associated with anterior pelvic tilt can include:

  • low back pain
  • incontinence
  • pelvic instability
  • upper cross syndrome
  • abdominal distention
  • nerve impingement
  • lumbar lordosis
  • strain on the Lumbar Vertebral and Sacroiliac Joints.


Characteristics of Anterior pelvic Tilt

  • lengthened (weak) hamstrings, abdominals ,glutes
  • shortened (tight) erector spinae, hip flexors

Due to the neurological connection ,other muscles in the deep stabilization mechanism may become dysfunctional. This may include the pelvic floor and lumbar multifidus.

Posterior Pelvic Tilt[edit | edit source]

When the human body is forced to hold itself up against gravity, it will naturally seek out the most stable , least fatiguing position. When a person is seated ,the position of stability is often a posterior pelvic tilt, as it lowers the center of gravity. In layman's terms, posterior pelvic tilt looks like slouching.

During prolonged sitting, shoulders are drawn forward and tight, upperback is hunched and abdominal muscles and gluteal muscles are inhibited, calves and hamstrings are short, tightened and underused, psoas is under constant tension. These factors even contribute to Diastasis Recti.

Posterior pelvic tilt can cause the pelvic organs like the bladder and bowels to descend through the vaginal wall due to constant pressure caused due to poor posture. In hypo-lordosis ,the PFMs are oriented approximately perpendicular to the vaginal canal. If the pelvic floor muscles are incompetent (either too tight or too long and weak to work well) to support, it can lead to pelvic organ prolapse.

Poor posture can also lead to stress incontinence which is the involuntary leakage of urine on laughing, sneezing or coughing. Slouching increases abdominal pressure, which puts pressure on the bladder .Also, this position decreases the ability of the pelvic floor muscles to hold against/counteract the increased abdominal pressure affecting the urethral sphincter closure pressure causing bladder control issues.

Characteristics of posterior pelvic tilt

  • shortened (tight) hamstrings, abdominals, gluteus
  • lengthened (weak) erector spinae, hip flexors.

Forward Head Posture[edit | edit source]

[[3]]

Forward head posture is a poor habitual neck posture that is defined by hyperextension of the upper cervical vertebrae and forward translation of the cervical vertebrae. Forward head posture increases compressive loading on tissues of the cervical spine, particularly the facet joints and ligaments. This can lead to symptoms such a headache, neck pain, temporomandibular pain, and musculoskeletal disorders related to forward head posture. Also, it greatly influences the respiratory function by weakening the respiratory function by weakening the respiratory muscles.[5][6]

Ideally , a normal posture is where the ears is positioned directly over the shoulder. The head normally weighs 10-12 pounds. For every inch the head moves forward out of the normal posture, the weight of the head increases the pressure on the cervical spine by 10 pounds. Aligning the head with the neck and spine helps reduce the stress put on the pelvic floor.

A slumped body position commonly involves head protruding forward, rounded shoulders, a flat low , with hips displaced forward and/or a protruding abdomen. This posture places excessive pressure on the pelvic organs and pelvic floor which can worsen urinary incontinence, pelvic pain and symptoms related to prolapse and rectus diastasis.

Lateral Pelvic Tilt[edit | edit source]

Lateral pelvic tilt is when the pelvis shifts side to side ,such that one hip is higher than the other. This can lead to unilateral muscle imbalances throughout the body. Usually erector spinae group of muscle affects this tilt. Causes for lateral pelvic tilt could be due to functional changes from muscular tightness and structural problems resulting from limb length discrepancy. Sacroiliac joint dysfunction or scoliosis are few examples .These imbalances can affect the muscles of the pelvic floor.

Weak Gluteal Muscles and Tight Pelvic Floor[edit | edit source]

Weak gluteal muscles causes bad posture. Strong pelvic floor is good but, too-tight Pelvic floor can pull sacrum forward promoting even more weakness , and more pelvic floor gripping. The muscles that balance out the anterior pull on sacrum are the glutes. Zero lumbar curvature is the most telling sign that the pelvic floor is beginning to weaken. An easier way to say this is: Weak gluteus+ too many Kegels= PFD( pelvic floor dysfunction)- Katy Bowman .

For some women with pelvic organ prolapse, the problem is actually short, tight, overly active pelvic floor muscles rather than weak pelvic floor muscles. Therefore muscles that are always tensed become weak.

Posture and Breathing[edit | edit source]

[[4]]

Normally, the respiratory muscle diaphragm moves incoordination with the pelvic floor muscles. During inspiration, the diaphragm contracts descending downward while the deep abdominal muscle ( transverse abdominis) relaxes and the pelvic floor muscle descends as well. Likewise , during exhalation, the diaphragm rises up underneath the ribcage to expel the air and the pelvic floor muscles lifts as well .This breathing pattern encourages the pelvic floor muscles to move more dynamically. Dysfunctional breathing patterns inhibit this dynamic movement of pelvic floor muscles .Stiff pelvic floor muscles are weak and insufficient contributing to pelvic floor dysfunction. [7]

While breathing with slumped flexion posture of the spine, it is difficult to fill the lungs and breathe deeply. This is because in slumped forward posture, abdominal contents become compressed preventing the diaphragm from moving downward creating the need to use upper chest muscles to help breathe.[[5]]

Slumped forward position and breathing with upper chest muscles increases pressure on the pelvic floor and reduces the ability of the deep abdominal and pelvic floor muscles to counteract this increased pressure. This is why correct posture is very important in helping the diaphragm, pelvic floor and abdominal muscles to work well together. Dysfuncional breathing is closely related to failure in intra-abdominal pressure as well as deep stabilizer activity and also in diaphragm and PFM disorders.[8]

https://youtu.be/8uMiz1Zx1r0

Importance of Neutral Posture[edit | edit source]

Neutral posture involves alignment of head over shoulder over hips over heel. A neutral pelvic alignment refers to actually tilted forward pelvis-less than 5 degrees for men and 10 degrees for women which causes a small lordotic curve of the lumbar spine. Both an anteriorly or posteriorly tilted pelvis will put the entire core into non-optimal position. Normally ,adopting neutral thoraco-pelvic postures in sitting and standing automatically facilitates better deep system activity without activating the large superficial muscles. Maintaining the body in good alignment has the following advantages:

  • gives body biomechanical advantages to function with ease and minimal effort.
  • improves pelvic floor engagement
  • promotes deep abdominal muscle activity which also play an important role in supporting the pelvic organs and promote bladder and bowel control.
  • it enhances diaphragmatic breathing that enhances pelvic floor muscle activity.

Pelvic Floor Muscle Activity in Sitting[edit | edit source]

It has been shown that using back rest (leaning against the back rest of a chair) decreases pelvic floor muscle activity compared to unsupported sitting.[9] While it is important to use back rest to support the spine when sitting for extended periods of time, it is advisable to move forward away from the back of the chair while performing pelvic floor exercises for optimal recruitment of pelvic floor muscles. Also a study performed confirms increased activity of the PFMs and the two abdominal muscles namely the external and internal obliques during various sitting positions. Their highest activity was observed in the very tall unsupported postures. It has been concluded that unsupported sitting postures require greater pelvic floor muscle activity than supported.[10]

Sitting posture needs to be addressed ,especially as most new mothers do this for a significant portion of their day during feeding and even after returning to desk bound jobs. Many women with pelvic core neuromuscular system dysfunction[11] present with a posterior pelvic tilt and decreased lumbar lordosis.

Despite optimal PFM EMG activation being found in the neutral posture, this posture was not the ideal position for the generation of intra-vaginal pressure. Higher pressures may be produced in the hypo-lordotic position due to the orientation of the PFMs relative to the vaginal lumen .Although the PFMs are not contracting as strongly in this position, intra-vaginal pressure may be maximized due to optimal transmission f the anterior forces generated through PFM contraction squeezing the vaginal lumen between the pubic symphysis and the PFMs.

In a normal or hyper-lordotic posture , the PFM contraction may create lower resultant closure forces because the force vector is further away from being perpendicular to the vaginal lumen in there postures.

Pelvic Floor Muscle Activity in Standing[edit | edit source]

The true angle between the vaginal lumen and the pelvic floor is approximately 45-60 degree when women stand in an upright posture. Studies have shown that tonic PFM EMG activity was higher in all positions ( habitual posture ,hypo-lordosis and hyper-lordosis as compared to supine. Also higher EMG activity of levator ani muscle group of the Pelvic floor was found in standing position as compared to recumbent position. The tonic activity of PFM was significantly higher in the hypo-lordotic posture as compared to habitual posture.[9]

Assessment[edit | edit source]

External Musculoskeletal and Lumbopelvic Assessment[[6]][edit | edit source]

  • Posture -Upright posture versus rounded shoulders, forward head
  • Gait/mobility -Toe out, Trendelenburg, Speed
  • Alignment -Shoulder height, Anterior superior iliac spine , Iliac crest (anterior and posterior) ,Posterior superior iliac spine, Popliteal folds
  • Abdomen Scar-Diastasis recti, Trigger point, (Carnett test)
  • Lumbar spine -Lumbar range of motion, Seated slump test
  • Pelvic girdle -Sacroiliac tests, -Active straight leg raise test , Pubic symphysis palpation
  • Hip -Pain provocation, Range of motion, Strength testing
  • Strength/stability-Sit to stand ability and form, Squat ability and form ,Step up ability and form, Core stability


First and foremost in order to design the corrective exercises we need to determine the pelvic tilt the patient presents with. Asymmetrical range of motion of the hip joints and pelvis may lead to changes in muscle and tendon length as well as function. After explaining to the patient the findings and the surrounding anatomy ,to confirm the finding about their pelvic tilt, tests can be performed .This builds the trust between the patient and the therapist and helps in designing the corrective exercise program to fix their pelvic tilt. The following tests can be performed to confirm the findings for:

  • Anterior Pelvic Tilt- Thomas Test
  • Posterior Pelvic Tilt-The position of the posterior superior iliac spine in relation to the anterior superior iliac spine
  • Lateral Pelvic Tilt- Trendelenburg Test

Pelvic Floor Assessment[edit | edit source]

  • Assessment of the superficial PFMs
  • Assessment of the deep PFMs
  • Assessment of the trigger points.
  • Assessment of PFMs strength and relaxation

Pelvic floor assessment per vaginum helps in diagnosing the asymmetry within the pelvic floor muscles or the dysfunction caused due to asymmetry of the surrounding muscles .Pelvic floor asymmetry may be due to unilateral hypertonicity or paravaginal defects in the endopelvic fascia.

Physiotherapy Management[edit | edit source]

After a proper evaluation , the management would include mainly Postural Awareness, Corrective exercises like finding the neutral posture using pelvic tilt[12], strengthening of weak muscles and stretching of tight muscles, trigger point release and Diaphragmatic Breathing with proper alignment of the body.

Correct posture for optimal Pelvic Floor Muscle activity[edit | edit source]

According to Biomechanist Katy Bowman ' pelvic floor health depends on the natural movement (i.e. walking, squatting, kneeling, lifting , changing positions) done throughout the day." Correct posture for successful pelvic floor exercise involves finding ones neutral posture and maintaining it throughout the various activities performed during the day.

  • Avoid slumped forward posture
  • Avoid remaining in a single static posture for prolonged duration of time instead keep moving.
  • Sit away from the back of the chair or use an exercise ball during siting if the aim is to strengthen pelvic floor muscles.
  • Since hypo-lordotic posture resulted in higher tonic activation of PFMs ,this posture may be a good posture to facilitate PFM contraction in women who have difficulty activating their PFMs voluntarily
  • Coughing induced a larger PFM contraction than the other tasks and would be an useful approach to initiate strengthening of the PFMs in women who have difficulty activating their PFM voluntarily.
  • Instructing patients with hyper-lordosis to decease their lumbar curve while contracting their PFM may help prevent urine leakage during tasks that increase intra-abdominal pressure.
  • Ribs over hips allows optimal ability of muscular force generation of the core muscles for this it is important to find neutral spine which is possible by performing pelvic tilt by taking the pelvis through the anterior and then the posterior pelvic tilt and then bringing it to neutral.

{{https://youtu.be/hanL95BJO_A}}

Correct Standing Posture[edit | edit source]

  • Stand with feet hip width apart
  • Balance weight evenly
  • Lengthen spine by lifting the crown of the head towards ceiling
  • Tuck chin in slightly so that it is not poked forwards
  • Relax shoulders back and down
  • Maintain the normal inward curve of lower back.

Correct Sitting Posture[edit | edit source]

  • Sit on a chair, stool or exercise ball.
  • Position feet about hip width apart
  • Balance weight evenly between sit bones
  • Lift the crown of head towards the ceiling
  • Tuck your chin in slightly so that it is not poked forwards
  • Bring your shoulder bladed back and slightly down and lift your chest
  • Lengthen your spine
  • Ensure to maintain the normal inward curve the lower back

Research also shows adjusting chair to about 135 degrees reduces the pressure on the back from sitting for long periods.

{{https://youtu.be/aoK8baXKT9I}}

Corrective Exercises for Anterior Pelvic Tilt[edit | edit source]

  • Lying Posterior Pelvic Tilt- core and gluteal strength
  • Lying Gluteal bridge-Gluteal and Hamstring strength
  • Half-Kneeling Hip Flexor Stretch-Releases tight hip flexors
  • Bird Dog-strengthens the glutes and core stability
  • Plank-Glute and Hamstring activation adjusting pelvis towards a more posterior position.
  • Dead Bug-Core and Hip stabilization to align the pelvis
  • Quad Foam Roll-Myofascial release technique for quadriceps and rectus femoris
  • IT Band Foam Roll -Release the tensor fascia latae and iliotibial band

Corrective Exercises for Posterior Pelvic Tilt[edit | edit source]

  • Seated Hamstring Stretch-Stretches tight hamstrings causing the pelvis to tilt backward
  • Superman-Strengthens weak glutes and lumbar spine
  • Cobra- Stretches weak abdominals and psoas muscle.
  • Leg Raises-Strengthen weak hip flexors
  • Standing Hip Raises-Strengthen weak hip flexors
  • Glute/piriformis Foam Roll- Release tight glutes
  • Hamstring Foam Roll-Release tight hamstrings

Corrective Exercises for Lateral Pelvic Tilt[edit | edit source]

  • Lying Reverse Leg Raise in prone lying
  • Standing Reverse Leg Raise
  • Clamshell Exercise-Helps strenghten the gluteus medius
  • Quadraus Lumborum Stretch
  • Side Lying Leg Lift-Strengthens Gluteus medius
  • Foam Roll Lower Back/Quadratus Lumborum

Breathing Exercises[edit | edit source]

A recent study proved that diaphragmatic breathing in which exhalation was longer than inspiration with repositioning of the pelvis helped to realign the pelvis. Therefore it is important to educate on proper breathing techniques to reduce asymmetry in the pelvic floor muscles[8]

{{https://youtu.be/xvQGxKst7sk}}

Conclusion[edit | edit source]

For the optimal functioning of the pelvic floor musculature posture plays a very important role. Some postures put the pelvic floor muscles in a very lax position while the other keeps it tensed throughout the day. These imbalances in the muscles can in turn cause low back pain, pelvic floor dysfunctions like pelvic pain, pelvic organ prolapse and incontinence. Motion is lotion .So avoidance of remaining in one posture for a prolonged duration of time is important .Also being aware of one's breathing and posture during the day would help perform with excellence.

REFERENCES[edit | edit source]

  1. Kieran O’Sullivan , Raymond McCarthy , Alison White , Leonard O’Sullivan & Wim Dankaerts (2012): Lumbar posture and trunk muscle activation during a typing task when sitting on a novel dynamic ergonomic chair, Ergonomics, 55:12, 1586-1595
  2. Mattox TF, Lucente V, McIntyre P, Miklos JR, Tomezsko J. Abnormal spinal curvature and its relationship to pelvic organ prolapse. Am J Obstet Gynecol. 2000 Dec;183(6):1381-4; discussion 1384. doi: 10.1067/mob.2000.111489. PMID: 11120500.
  3. Mattox TF, Lucente V, McIntyre P, Miklos JR, Tomezsko J. Abnormal spinal curvature and its relationship to pelvic organ prolapse. Am J Obstet Gynecol. 2000 Dec;183(6):1381-4; discussion 1384. doi: 10.1067/mob.2000.111489. PMID: 11120500.
  4. 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 Sep;89(9):1741-7. doi: 10.1016/j.apmr.2008.01.029. PMID: 18760158.
  5. https://commons.wikimedia.org/wiki/File:Bad_posture.jpg
  6. Lee HS, Chung HK, Park SW. Correlation between Trunk Posture and Neck Reposition Sense among Subjects with Forward Head Neck Postures. Biomed Res Int. 2015;2015:689610. doi: 10.1155/2015/689610. Epub 2015 Oct 25. PMID: 26583125; PMCID: PMC4637041.
  7. O'Sullivan PB, Beales DJ. Changes in pelvic floor and diaphragm kinematics and respiratory patterns in subjects with sacroiliac joint pain following a motor learning intervention: a case series. Man Ther. 2007 Aug;12(3):209-18. doi: 10.1016/j.math.2006.06.006. Epub 2006 Aug 17. PMID: 16919496.
  8. 8.0 8.1 Oleksy Ł, Mika A, Kielnar R, Grzegorczyk J, Marchewka A, Stolarczyk A. The influence of pelvis reposition exercises on pelvic floor muscles asymmetry: A randomized prospective study. Medicine (Baltimore). 2019 Jan;98(2):e13988. doi: 10.1097/MD.0000000000013988. PMID: 30633181; PMCID: PMC6336649.
  9. 9.0 9.1 Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Man Ther. 2004 Feb;9(1):3-12. doi: 10.1016/s1356-689x(03)00131-0. PMID: 14723856.
  10. Sapsford RR, Richardson CA, Stanton WR. Sitting posture affects pelvic floor muscle activity in parous women: an observational study. Aust J Physiother. 2006;52(3):219-22. doi: 10.1016/s0004-9514(06)70031-9. PMID: 16942457.
  11. https://www.physio-pedia.com/Low_Back_Pain_and_Pelvic_Floor_Disorders?title=Physiopedia:Privacy_Policy
  12. https://youtu.be/hcTEUKp7zsY