The Alignment Cure

The Alignment CureGoogle around and you’ll notice “alignment” is the new diastasis recti and prolapse buzzword (If you have found my obscure blog, I assume you have Googled around).

The emphasis on alignment varies according to source, with the Rhapsodic claiming alignment as the cause and cure of practically all ills, including core and pelvic floor problems, and the Measured blessing neutral posture.

How can you tell the difference? The Rhapsodic claim that a very narrow version of alignment will stop disease and your body from “wearing out.” The Measured do not.

Although the abecedarian enthusiasm for what I am calling “the alignment cure” is at an all time high, remember, the internet can give the illusion of an informed choir when we are really hearing the echo chamber’s refractions. [Tweet this]

Let’s Start at the End

Does proper alignment close a diastasis recti and help pelvic floor disorders?

Short Answer: I don’t know, and neither does the evidence.

Long Answer: Keep reading.

A False Dichotomy

I don’t want to create a false dichotomy by separating alignment into something you can be for or against.

Let me be clear, I believe thoughtful alignment[1] is helpful. It’s the degree I quibble over.

I’m inclined to believe that alignment sometimes affects how your muscles activate and how you breathe, which in turn might affect your intra-abdominal pressure, which ultimately might affect the loads placed on your pelvic and abdominal diaphragms. (Or maybe it doesn’t do any of that.)

But, I’m starting to think alignment is overhyped.

Often, alignment is portrayed as the simple, albeit not easy, path to recovery.

Simple, But Not Easy

Those words are enticing: “Simple, but not easy.”

I love that phrase. I like clarity. I’m a hard worker. Give me a clear goal and set me off.

Oh, how I tried.

Did Alignment Solve My Problems?

Probably not.

I had obsessed over alignment—based on some online advice—for a year after the birth of my first kid, while abandoning Kegels (really really bad idea). My symptoms remained unimpressed by my awesome posture.

After my second kid, I finally saw a women’s health physical therapist whose alignment advice differed from the online source I had been dutifully following.

Then I saw another physical therapist who gave me yet another perspective on alignment.

3 professionals. 3 different versions of correct alignment.

I was confused, but since both physical therapists had emphasized proper pelvic lifts (also known as Kegels), I reincorporated them into my life. They helped me a lot. I cursed myself for having abandoned them so quickly after my first child.

Reincorporating Alignment

In combination with pelvic lifts, I started to play around with the posture advice from my physical therapists, this time focusing on how my pelvic floor and abdominal muscles actually felt in different positions.

It was play, not prescription.

My pelvic floor muscles were weak and possibly stiff. I had made them stronger via proper Kegels, but I wondered if they were limber enough.

Playing with my posture helped ameliorate some of the stiffness. Maybe. In any case, alignment was like an extra pep in my pelvic floor’s step, but not the one stop solution. Also, just like the Kegel, alignment isn’t going to fix internal damage to ligaments and organs.

Let me back up.

What is Alignment Supposed to Do?

A couple theories, some more plausible than others:[2]

The less plausible first: This theory says you need to stretch and align yourself EXACTLY RIGHT so that you walk EXACTLY RIGHT, so that the gravitational forces flow through your bones and pelvic floor EXACTLY RIGHT, and, if you don’t DO alignment exactly right, your vagina and belly don’t have a chance, but if you do DO alignment, everything will be perfect.

The second, more plausible but still unproven, theory: How you carry your body will affect the rectus abdominis’s ability to come back together and will also affect the pelvic floor’s ability to remain continent. It may also prevent prolapse from progressing. Since a DR is often associated with prolapse, the alignment advice for each condition overlaps.

For example, if you constantly stand with your boobs pointing upward and your upper back hovering behind your center of gravity, you are a back clencher (guilty as charged). If your pelvis tilts backwards, flattening your lumbar lordosis, you are a butt clencher (innocent). If your pelvis falls too far forward, you are over-stretching your abdominal and pelvic muscles.

(Confused? Read What is Neutral. Also, remember, posture variations may not matter that much, at least they don’t for pain.)

Back Gripping vs. Neutral
Picture 1 is back gripping also called rib thrusting. Picture 6 is neutral. Originally found in “What is Neutral?”

Why don’t you want to thrust the ribs and tuck the pelvis?

According to this theory, you want your abdominal canister to “fire” appropriately when faced with a load, such as lifting your kid. If it can’t fire properly, your innermost abdominal muscles and your pelvic floor muscles can’t engage. Unengaged muscles can’t prevent downward pressure from doming out your belly and can’t close off the urethra so you don’t pee yourself.

Furthermore, the theory goes, if your abdominal canister is not aligned properly, your breathing patterns are compromised.

I’ll use myself as an example. I tend to be a chest breather when under stress. When I do this, my lower ribcage doesn’t fully expand. In turn, the loading pressure that my pelvic floor needs doesn’t materialize and my abdominal muscles over-brace, while my stiff pelvic floor freaks out (this theory assumes my pelvic floor is stiff, which may or may not be true).

It seems like a paradox, but it’s not. In this scenario, both my abs and my pelvic floor are over-activated. The over-activation of my abs sends pressure to my pelvic floor, and just at the moment when I need my pelvic floor to contract and stop that pressure from pushing pee out, they freeze.

They are like deer caught in a headlight, stiff, but weak and vulnerable. The deer needs to un-stiffen its legs and then contract them again to run away. My pelvic floor needs to un-stiffen, relax a little, and then contract appropriately, all without me thinking about it.

Does adjusting posture help the pelvic floor un-stiffen and fire appropriately? Or does simply thinking about the pelvic floor make these changes, regardless of posture adjustments? Hmmm.

Additionally, are stiff pelvic floors even the predominant problem in postpartum women or are weak and overly compliant pelvic floors the problem? My money is on the latter.

Are the Theories True?

From what I can tell, the experts agree that the pelvic floor needs to relax before firing.

However, they don’t always agree on the best alignment to support these pressure systems.

Can you fire the muscles appropriately in many different postures? I don’t know.

How important are minor postural changes? Wish someone could answer that.

Are we encouraging stiffer postures by prescribing a limited right way to stand and walk? I think yes.

Ah, But What Does Alignment Have to Do with Diastasis?

This is where my alignment ambivalence kicks in. Some people say if you properly align your rib cage over your pelvis, letting the pelvic diaphragm expand and contract properly, that pesky diastasis will naturally correct itself.

The theory assumes readjusting pressure patterns will take the pressure off the linea alba and, viola, your diastasis recti disappears.

The image of a zipper gets a lot of traction. According to this analogy, you have a zipper from your rib cage to your pelvic floor. Once you take the kinks out of the zipper, it can zip itself back up.

Your Belly is a Rubber Band

I love the zipper as an exercise cue, but not as an explanation. It is too neat for me. The linea alba is probably more like a series of rubber bands. If you stretch the rubber bands a little, they can bounce back. If you stretch them too much or for too long, they won’t—even if the pressures are restored. Because, let’s be honest, the pressure of slightly unstacked ribs on top of a slightly titled pelvis is nothing compared to the pressure of giant babies.

Maybe taking the slack out of the rubber-bands will help position the rectus abdominis more naturally, but, for many women, this won’t zip the rectus abdominis back together.

So far, I’m unconvinced sustained micro-pressure can rival temporary macro-pressure (pregnancy) in causing damage.

Let me mix analogies: Even if you were able to maintain proper alignment most of the time—the definition of which isn’t agreed upon— your zipper won’t just zip itself up if the rubber bands have been stretched too far.

Alignment Apostle to Apostate

Early in this process, I was assured if I got my alignment under control, my diastasis would close (Note, a physical therapist didn’t say this to me; it was another professional. Physical therapists are smart enough to know bodies are messier than that).

I obsessed over how I was standing. I checked myself in the mirror over and over. I measured. I bought alignment apps. I took pictures. I made my husband stare at me. I told other people they were standing inappropriately.

I turned myself into a neurotic alignment apostle.

Over time, my posture did improve. I stopped thrusting those ribs back. I maintained a good neutral arch in my lower back. I noticed my abdominal muscles turning on.

Wait, but maybe I was turning on the wrong abdominal muscles.

Maybe I was just causing more downward pressure.

Maybe I was fooling myself that I wasn’t thrusting.

Maybe my pelvis wasn’t tilted just right.

Maybe I screwed everything up by lifting my kid the wrong way that one time.

And oh God! I’m not moving. In. Proper. Alignment. At. This. Very. Moment.

Is all this focus on alignment just stressing me out and is that stress transferring to my pelvic floor? Am I making it weaker by trying to make it more supple? Damn.

Unrealistic Expectations

During my peak positive posture adherence, my gap didn’t close. Didn’t even get smaller. The benefits of better posture didn’t obviously correlate to any changes in my body.

You might say my expectations were unrealistic, and I completely agree. I wanted unrealistic results, but the internet flamed these expectations.

Those touting the alignment cure claim it will fix a diastasis. And if it doesn’t, the problem is you, not the theory.

If the whole point of doing anything is to improve your quality of life, I’d give my alignment devotion a failing grade.

The Evidence is Not in Step with the Theory.

Perhaps the benefits are subtle, which is fine if you can improve your posture without going crazy, but that’s not how the alignment cure is advertised.

They don’t say, “every once in a while check your alignment for possible subtle benefits to your abs and pelvic floor.” They say “if you don’t maintain proper alignment, you will never see improvement in the function of your pelvic floor or abdomen.”

They also do not put enough emphasis on the myriad causes of incontinence and prolapse and weak pelvic floors and diastasis recti that have absolutely nothing to do with the way you carry yourself, and therefore cannot be fixed by such.

Obviously, this does’t mean “proper” alignment has no benefit; rather, alignment needs to be put into a much larger context, not highlighted as the one true way.

And (this is a big AND) if you are going to obsess about something, it might as well be proven. I want more bang for my obsessive buck.

What Do the Studies Say?

Fine, but Meredith, you are one person and your anecdotal experience doesn’t invalidate the alignment cure.

True. However, I don’t need to prove a negative.

Some incredibly small and preliminary studies have looked at pelvic floor muscle activation in different postures, but I wouldn’t call it conclusive. Read more in Does Neutral Posture Matter?

From what I gather, the studies tend to support a “neutral” posture and show different levels of external abdominal activation in women with stress urinary incontinence compared to women without. Unfortunately, measuring activation is not the same as measuring pressure systems, so all in all, we’ll call the actual evidence not so great, but the theoretical and anecdotal evidence middling. In other words, your alignment may make a difference in how your pelvic floor functions.

As for a diastasis, I couldn’t find anything. This doesn’t mean posture correction won’t help, but it does mean we don’t have any evidence, not even preliminary stuff.

Conclusion

This post was messy. This is because my thoughts are messy. I know I’ve jumped back and forth between pelvic floor issues and diastasis recti, but, to be fair, they are intimately connected.

I’m also not a scientist, so my thoughts are bubbling in a fairly ignorant, although skeptical, mind, which can be a dangerous cauldron (I am skeptical enough to know this and ignorant enough to write down my thoughts anyway).

Some alignment advocates might think I’ve created a straw man argument out of their particular approach. I’ve combined a lot of different advice, so this may be true. Some advice is nuanced. Some isn’t.

Don’t Abandon Neutral Posture

Although I’ve questioned the alignment dogma, ironically, I encourage attention to how you carry yourself. The baby really doesn’t want to be thrown out with the bathwater (Luckily, we have drains now). Decent posture can be encouraged without subscribing to the alignment cure.

And guess what. My diastasis eventually narrowed. HOWEVER, I have no idea if my posture helped it narrow, if my exercises helped it narrow, if time naturally helped it narrow, if my lucky underwear helped it narrow, etc… We biological beings are hard nuts to crack.

Want to know more about diastasis recti? Then check out the 60+ Page Essay “Why Diastasis Recti Experts Disagree.” 

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  1. Some may object to my conflation of “alignment” and “posture.” However, for all intents and purposes, the terms refer to the same tenor of advice. Many would say “good posture” is “being in alignment.” Oh, and when I say “alignment” I mean “proper alignment.”  ↩
  2. A certain online guru advocates hyperlordosis, claiming we should walk more like dogs. This version of alignment has been rejected by every other professional I’ve brought this up with.  ↩

2 thoughts on “The Alignment Cure

  1. Very interesting post. Thank you for getting all the details out there. I’ve found a ton of help for my prolapse with alignment but, as you mentioned, it is not easy and has actually been a long road for me – over 3 years. Kegels, which are supposedly just a temporary fix anyway, really don’t help me much. When I am “properly aligned” – whatever that means, ha, ha, my prolapse is undetectable, but when I get tired as the day goes on I do feel it – BUT so much less than I used to. The pressure was quite scary at one point. I was able to get a ton of helpful advice from Laura Ohayon over at Holy Shift Yoga. Here Facebook group Restore Your Core has been beyond helpful. Yes, she is a Nutritional Movement Practitioner but also has an extensive background in other modalities. Her advice on breathing is priceless – I would get symptomatic from planks but that has been fixed. Lately I have found Foundation Training exercises to be very helpful but I make sure to keep my ribs down & breath into my ribs.

    1. I’m glad that is has helped you. It is a long road, no matter which path we choose. Although sometimes I worry about how we can test the validity of alignment as an intervention strategy. Frankly, if it helps an individual, that is great, but in terms of global recommendations, I would love to see more evidence, or really any good evidence. I found that working out and getting stronger naturally helped pull me out of hyperlordosis, but, as you say, everybody is different.

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