Hypo-ed up? Hypopressives for pelvic floor dysfunction

In a previous season of life, I lived in Qatar and working at a interdisciplinary sports hospital.  I loved learning about physiotherapy culture around the world.  The Greeks used a wheel, the Tunisians loved rotational patterns, the Australians swore by load progressions, the Scandanavians prescribed eccentric exercises, and the Brazilian/Portuguese/Spanish—they had hypopressive abdominal exercises.  Hypopressive exercises were magic exercises that solved low back pain, prolapse, incontinence, and diastasis recti abdominis.  So of course, I wondered, “Are Americans missing the boat?” 

What are hypopressive exercises?  And how do they work?

Hypopressive abdominal exercises (HAE) were developed by Marciel Caufriez as a response to the obsession with “the core” and the corresponding exercises (primarily crunches) that would increase downward pressure.  Hypopressive abdominal exercises use a pressure gradient between the thorax and abdominal cavity to create a “vacuum” effect.  By creating a vacuum that draws pressure upward, your body automatically recruits transverse abdominis (TrA) and pelvic floor muscles (PFM).   The HAE sequence begins with static positions and progresses to dynamic and difficult movements.  The set up for the exercise:

1. Three breaths filling the ribs making sure the sides are expanding.  

2. Breathe in focused on expanding ribs out and lower ribs up while minimizing belly movement.

3. Then, breathe out working on spinal elongation and keeping ribs up and out.  Hold the exhale for creating the vacuum and relaxing the diaphragm.  The belly button should start to move up.

4. Close the throat as if you were at the end of a swallow to lift, expand, inflate rib cage further increasing the vacuum and pressure differential—like an inhale, but without taking in air.

For the hypopressive vacuum, inhalation relies upper chest and neck muscles instead of the respiratory diaphragm and intercoastals.  The inhalation lifts the rib cage up and gives more volume and lowers the above the abdomen.  The exhalation activates the pelvic floor and transverse abdominis to compress the abdomen which increases the pressure of the abdomen.  The pressure difference between the diaphragm is augmented by the closed inspiration and creates the vacuum that creates the automatic response.  With HAE, the abdominal cavity has the same increase in pressure, possibly more, than with diaphragmatic breath, but because of the suction upwards, feels like a different pressure.  In diaphragmatic breath, inhalation causes the diaphragm to descend which increases intra-abdominal pressure and a reflexive eccentric contraction of the pelvic floor and abdominal wall.  Exhalation is a passive return to the diaphragm’s resting position and if it is a complete exhalation, the pelvic floor and transverse abdominis will also contribute some activity.    

What’s the relationship between hypopressive exercises and core coordination?

As measured by surface EMG and dynamic ultrasound, HAE consistently have comparable or less activation of the pelvic floor muscle and transverse abdominis than isolated, well-cued exercises (1-4).  However, to increase TrA contraction, HAE with pelvic floor muscle contraction recruits more fibers more than pelvic floor contraction alone (4).  HAE biases activation of deeper stabilizers--transverse abdominis, internal obliques, and pelvic floor over rectus abdominis and external obliques(6). No research has evaluated the HAE claims of decreased downward abdominal cavity pressure.  While HAE are progressed with consideration for increasing challenge, they are not incorportated into everyday positions which has an impact on the body’s ability to integrate into a task. 

So, will hypopressive exercises fix my problems?

The solution for downward pressure gone wrong is not forcing upward pressure, but addressing why the body lost its adaptability for life’s demands.  I rarely use hypopressive abdominal exercises as treatment for problems of the pressure system--pelvic organ prolapse, stress incontinence, diastasis recti abdominis, lumbar disc herniations, and ventral hernias.  Studies show that HAE do not have an advantage over conventional TrA and PFM exercises (8) in losing postpartum weight (9), improving pelvic organ prolapse symptoms (2,4,5), or correcting diastasis recti (10).  In addition, the time, patience, and healthy lifestyle post-partum patience also great healers. 

Besides being less effective than conventional exercises for strengthening and symptom relief, HAE exchange downward and outward pressure for upward pressure and compensatory muscle patterns.  This could show up as gastroesophageal reflux disorder (GERD), hiatal hernias, hyperinflated lungs with increased sympathetic drive (and immediate light headedness), restricted diaphragm, forward neck posture, or thoracic outlet syndrome.  The respiratory diaphragm has a mechanical advantage for respiration over upper chest and neck muscles which have other postural functions. 

Escaping gravity is not yet sustainable which means, normal life—breathing, digestion, walking, and laughing—includes downward pressure.  If the goal is to decrease pressure on the pelvic floor, lying down with hips elevated, headstand, downward dog, or inversion table—none of these translate into movements of everyday life, but also do not alter the body’s normal respiration and stabilization patterns.  “First do no harm.”

If someone is having difficulty isolating the pelvie floor muscles and transverse abdominis, I would connect with diaphragmatic breath, vary effort level, try different verbal and manual cues, and modify the relative position of the pelvis to the spine (7).  After correcting the mechanical “pressure problem,” I would use HAE if an individual is still having great difficulty identifying the transverse abdominis and over-recruiting the rectus abdominis.  But, I then I would progress out of HAE to a isolated strengthening progression integrated into functional movements.  HAE is also one of many tools that can help in decreasing acute low back pain associated with muscle spasm. 

I acknowledge the benefits of hypopressive practices for posture, digestion, invigoration, and automatic recruitment of core stability.  But let’s also remember the time-tried basics of a healthy movement-filled lifestyle.  As more studies are published, I look forward to learning more about subgroups and larger functional goals for which HAE have benefit.  For now, the magic bullet for pelvic floor dysfunction is not hypopressive abdominal exercises.  Isolated pelvic floor and transverse abdominis activation may be old-school, but are well-researched with strong support and are overwhelmingly more beneficial than HAE at addressing symptom alleviation and muscle strengthening.  

Looking for pelvic health physical therapy in Philadelphia?

If you want more individualized treatment including education, exercise, and manual therapy, we would love to help you continue your favorite activities. This personalized care can make a meaningful difference.  At Hazel Physical Therapy, we provide pelvic floor physical therapy, prenatal physical therapy, and postpartum care in Philadelphia to help you move with less pain and more confidence. Let's connect to see how pelvic health physical therapy might help you in your recovery. 

References

1.  Brazalez BN, Lacomba MT, Mendez OS, Martin MA.  The abdominal and pelvic floor muscular response during a hypopressive exercise: dynamic transabdominal ultrasound assessment.  Br J Sports Med.  2018;52(Suppl 2):A22

2.  Resende AP, Stüpp L, Bernardes BT, Oliveira E, Castro RA, Girão MJ, Sartori MG. Can hypopressive exercises provide additional benefits to pelvic floor muscle training in women with pelvic organ prolapse?. Neurourology and urodynamics. 2012 Jan;31(1):121-5.

3.  Resende AP, Torelli L, Zanetti MR, Petricelli CD, Jármy-Di Bella ZI, Nakamura MU, Júnior EA, Moron AF, Girão MJ, Sartori MG. Can Abdominal Hypopressive Technique Change Levator Hiatus Area?: A 3-Dimensional Ultrasound Study. Ultrasound quarterly. 2016 Jun 1;32(2):175-9.

4.  Stüpp L, Resende AP, Petricelli CD, Nakamura MU, Alexandre SM, Zanetti MR. Pelvic floor muscle and transversus abdominis activation in abdominal hypopressive technique through surface electromyography. Neurourology and urodynamics. 2011 Nov;30(8):1518-21.

5.  Bernardes BT, Resende AP, Stüpp L, Oliveira E, Castro RA, Jármy di Bella ZI, Girão MJ, Sartori MG. Efficacy of pelvic floor muscle training and hypopressive exercises for treating pelvic organ prolapse in women: randomized controlled trial. Sao Paulo Medical Journal. 2012;130(1):5-9.

6.  Ithamar L, de Moura Filho AG, Rodrigues MA, Cortez KC, Machado VG, de Paiva Lima CR, Moretti E, Lemos A. Abdominal and pelvic floor electromyographic analysis during abdominal hypopressive gymnastics. Journal of bodywork and movement therapies. 2018 Jan 1;22(1):159-65.

7.  Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Manual therapy. 2004 Feb 1;9(1):3-12

8.  Martín-Rodríguez S, Bø K. Is abdominal hypopressive technique effective in the prevention and treatment of pelvic floor dysfunction? Marketing or evidence from high-quality clinical trials?. Br J Sports Med. 2017 Sep 4:bjsports-2017.

9.  Sanchez-Garcia JC, Rodriguez-Blanque R, Sanchez-Lopez AM, et al.  Hypopressive abdominal physical activity and its includence on postpartum weight recovery: a randomized control trial.  JONNPR. 2017; 2 (10): 473-483.

10.  Gomez FR, Senin-Camargo FJ, Cancela-Cores A, et al.  Effect of a hypopressive abdominal exercise program on the inter-rectus abdominis muscle distance in postpartum.  Br J Sports Med 2018;52(Suppl 2):A21