By Tamara Rial Rebullido @Tamara_Rial and Iván Chulvi-Medrano @IvanChulvi

We would like to highlight several historical and practical points of view that were overlooked in the discussion paper by Martín-Rodríguez and Bø . ¹ Firstly, a look through history of pelvic floor muscle (PFM) exercises dates back to ancient Chinese Taoism and Indian yoga traditions, millenians before Dr. Arnold Kegels work in the 1940s. Similarly, a close exploration into yoga practices allows us to identify the hypopressive breathing technique in the pranayama named Uddiyana Bandha. Interestingly, millenias before the scientific method era, yoguis practiced Uddiyanha Bandha in conjunction with Mula Bandha or what is the same as contraction of the PFM. Nowadays, this is also a worldwide practice from the yoga community.

Secondly, an inaccurate description of the technical basis of the hypopressive technique (HT) can lead to a misinterpretation of the data. The exercise description in the paper matches exactly with the one provided by Stupp et al.² However, both do not correspond with the technical protocol described in Caufriez,³ Rial and Pinsach⁴ or with clinical and public widespread practice.

To be more accurate, HT combines postural and breathing exercises performed in a supervised, rythmic and progressive sequence. ⁴ The basic fundamentals for all HT exercises involve: 1) spine elongation with neutral pelvis; 2) ankle dorsiflexion; 3) knee flexion; 4) scapular girdle muscle activation; 5) three normal breathing cycles which involve latero-costal breathing and slow deep exhalation; 6) breath-holding following rib-cage expansion and lift which involves the activation of the inspiratory muscles such as serratus anterior, sternocleidomastoid and scalene (not exclusively instercostal muscle) (figure 1). This breathing technique leads to a noticeable abdominal draw-in of the entire abdominal wall and expansion of the rib-cage.

Recently, an observational EMG study confirmed activation of the transverse abdominis and PFM when performing the standing, sitting and supine exercises of the HT.⁵ Previous knowledge and practical experience of the maneuvers involved in the HT should be considered essential when designing research protocols. Of note, Navarro et al.,⁶ found abdominal and PFM muscle activation during the HT using transabdominal ultrasound in women with two months of experience.

As noted by Martín-Rodríguez and Bø ,¹ there is not yet strong evidence for the use of other exercise programs for women with pelvic floor dysfunction. However, there is a growing body of evidence regarding the holistic benefits of postural and breathing exercise programs on health and quality of life. We are in the midst of a pandemic of physical inactivity in adults and, more specifically, in women with pelvic floor dysfunction. We need to widen the kegel lens in order to engage more women in exercise programs to delay the inevitable physical and psychosocial consequences of pelvic floor dysfunction.

Tamara Rial, PhD is the creator and co-founder of Low Pressure Fitness and has a special interest in hypopressive exercise and women’s health. Tamara has authored several books about the hypopressive technique and has lectured internationally on topics related to pelvic floor fitness. You can follow her on Instagram @tamararial or Twitter @Tamara_Rial

Iván Chulvi-Medrano, PhD, CSCS, CPT is an Assistant Professor at the University of Alicante, Spain. His research interests include resistance training for clinical populations and hypopressive exercise. You can follow him on Twitter @IvanChulvi

References

1. 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 Published Online First: 16 October 2017. doi:10.1136/bjsports-2017-098046.
2. 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. Neurourol Urodyn 2011;30:1518–21. doi: 10.1002/nau.21151.
3. Caufriez M. Gymnastique abdominale hypopressive. Bruxelles: M.C. Editions; 1997.
4. Rial T, Pinsach P. Hypopressive Techniques: Vigo: Cardeñoso; 2015.
5. Ithamar L, de Moura Filho AG, Benedetti Rodrigues MA, Duque Cortez KC, Machado VG, de Paiva Lima CRO, et al. Abdominal and pelvic floor electromyographic analysis during abdominal hypopressive gymnastics. J Bodywork Mov Ther 2017. doi: 10.1016/j.jbmt.2017.06.011.
6. Navarro B, Torres M, Arranz B, Sanchez O. Muscle response during a hypopressive exercise after pelvic floor physiotherapy: Assesment with transabdominal ultrasound. Fisioterapia 2017; 39: 187-94. doi: 10.1016/j.ft.2017.04.003.