A recent British study analyzed the evidence behind abdominal hypopressive technique for the treatment of urinary incontinence (UI) and pelvic organ prolapse (POP).1 This technique has been gaining notoriety across fitness and physical therapy industries in Europe, Canada, South America, and more recently in the U.S. However, the study found no sound evidence supporting its use.
Abdominal Hypopressive Technique (AHT) utilizes the diaphragm by having the patient breathe deeply on inspiration and contracting the abdominal muscles after fully breathing out and holding the breath before relaxing. The theory posed by its founders is that the exercise involuntarily contracts the pelvic floor muscles through reduced intra-abdominal pressure, thereby reducing symptoms of UI and POP.
Though AHT has been utilized in clinical practices for 20 years, the authors of the study note that no published evidence exists to support it. On the other hand, APTA SoWH Vice President Carrie Pagliano, PT, DPT is quoted in PT in Motion as saying, “There is some anecdotal, case-by-case support for this technique, and clinicians who use it in practice do identify hypopressives as a small component of treatment.”2
This sparks an interesting question as to how we lean on evidence versus anecdotal clinical reports. How do we analyze our knowledge of anatomy, physiology, and neuromotor control, and use that knowledge to determine which exercises are best for our patients? Evidence-informed and evidence-based clinical decision-making models are two hot topics now. Additionally, we as practitioners tend to use what we feel comfortable instructing, don’t we?
Lately I’m seeing more female athletes popping up in the clinic with pelvic floor dysfunction. From postpartum runners to nulliparous gymnasts and Crossfit athletes, more and more women are experiencing pelvic organ prolapse and stress urinary incontinence during their athletic endeavors.
A 2016 study by Ameida et al. examined urinary incontinence in female athletes who participate in high impact sports. 67 athletes were shown to be at high risk for UI, uncontrolled flatus, and sexual dysfunction compared to a control population of 96 non-athletes. The authors concluded that women involved in long-term high-impact and strengthening sports should be educated in the possible ramifications that these activities can have on pelvic floor function and offered preventive PFD strategies. 1
Education and awareness is key with this population, as they tend to ignore bodily discomfort and focus on their goals. Their body is an instrument and if the symptom is not pain they are apt to ignore it.
I have an educational video discussing the role of high impact sports on pelvic floor dysfunction for patients below, which can be used as a resource for educating patients.
Diaphragmic breathing has been a staple of pelvic floor treatment for decades. The relationship between the diaphragm and the pelvic floor is one likened to a piston, mechanically speaking, with the pelvic floor (PF) activating both in lift and squeeze during exhalation and increased intra-abdominal pressure.
Have you ever considered how forcefully you cue patients to breathe, and the role this may have on pelvic floor muscle activation? A quasi-experimental repeated measures study conducted by Kitani et al. sought to determine if force of expiration effected automatic activation of the pelvic floor muscles.1
Participants in this study were 26 nulliparous females age 18-35 years, all with normal activation of the pelvic floor muscles. A breathing device was utilized during the study to provide 3 different variations in resistance, measured with spirometry. Cranial displacement of the PF muscles was measured utilizing visualized ultrasound, while squeeze pressure of the PF muscles was measured using a perineometer.
The investigators found that of the three variations in force production during exhalation, a cranial-ventral pelvic floor displacement was found most often during minimum forced expiration during PF training aimed at enhancing displacement in an “optimum and protective direction”.
Clinically, this study reinforces the importance of cuing our patients to exhale gently during PF activation training. My verbal cues include “exhale gently as if you were blowing out birthday candles”, or “exhale gently as if you were trying to blow a feather across a table”.