(And why you should be doing it if you have a prolapse…..)

Background

Hypopressives first came onto my radar in 2017. As a Women’s Health Occupational Therapist specializing in treating peri & post-menopausal women, I had been looking for resources for my oldest patients who weren’t having success with traditional pelvic floor muscle training. I stumbled upon some promising research about the hypopressive technique and subsequently discovered the THE Dr. Tamara Rial, hypopressive researcher and co-creator of Low Pressure Fitness (LPF), would soon be teaching her first course in the US. In July 2018 I began my hypopressive journey as one of the first twenty-one OTs and PTs trained by Dr. Tamara Rial here in the United States. I’m writing this article to share with you what the research behind hypopressives objectively shows, and my personal experience with the technique as a Women’s Pelvic Health Therapist.

First things First: Terminology and History

Hypopressives/hypopressive exercise vs hypopressive apnea vs hypopressive gymnastics vs Low Pressure Fitness

There is a lot of confusing terminology around the practice of hypopressives. Hypopressive literally translates to “hypo” meaning low, and “pressive” meaning pressure. Colloquially, the terms hypopressives and hypopressive exercise are used interchangeably.

Hypopressives are not new. Historically, in Yoga practice a hypopressive maneuver called the Uddiyana Bhandha has been used for thousands of years for reported purposes such as visceral mobilization, respiratory muscle strengthening, and diaphragmatic mobility. Research findings demonstrate the Uddiyana bandha increases transverse abdominus muscle activation(1) and decreases pressure in the colon(2).

In the late 1970’s the hypopressive technique was adopted by bodybuilders, most famously Arnold Schwarzenegger, and renamed the “abdominal vacuum”. Bodybuilders posed using the technique to visually reduce their waist size while simultaneously highlighting their thoracic muscles.

Modern day hypopressive exercises were developed in the 1980’s in Europe by Dr. Marcel Caufriez specifically as a postpartum recovery technique for women experiencing pelvic organ prolapse and incontinence. You may also come across the term hypopressive gymnastics in the research literature when referring to the hypopressive exercises developed from this time frame.

The hypopressive apnea is the hallmark feature of hypopressive exercise during which after full exhalation, breath is held, the glottis is closed and the intercostal muscles are used to create inspiratory movement of the ribcage while the rectus abdominus muscle remains relaxed. This thoracic pressure change causes a “drawing up”of the relaxed diaphragm with associated decreased pressure in abdominal(4) and pelvic cavities(2).

Arnold Schwarzenegger, stomach vacuum

Arnold Schwarzenegger Stomach vacuum

Schwarzenegger, A. (1992) Bodybuilding Encyclopedia.

The video below demonstrates a hypopressive apnea:

Low Pressure Fitness (LPF):

In 2006 Dr. Tamara Rial and Piti Pinsach began teaching hyporessive exercise in Spain, based on their research findings supporting its use in resolving many different pelvic and abdominal dysfunctions. In 2014, they created Low Pressure Fitness (LPF), a full body exercise program integrating the hypopressive apnea with a progression of postural yoga-like poses. It’s important to make the distinction between LPF, and the hypopressive apnea. The apnea is one element of LPF. LPF can be done with or without the apnea and as we will see later, it may be undesirable for some people to perform the apnea. As a side note, LPF is now wildly popular in Spain as both a fitness regime and an aid in postpartum recovery.


LPF is touted as a method to(3):

  • ​Tone deep abdominal and pelvic floor muscles
  • Enhance posture
  • Prevent all types of herniation (abdominal, vaginal, etc.)
  • Regulate and/or improve respiratory parameters
  • Prevent and/or reduce the symptoms of urinary incontinence
  • Improve the management of intra-abdominal pressure
  • Improve venous return
  • Prevent musculoskeletal injuries
  • Improve lumbo-pelvic stabilization
  • Enhance quality of life and well-being

These are some pretty impressive assertions. Let’s first take a look at what the existing research tells us is physically happening during the hypopressive apnea.

What Is Demonstrably Happening During the Apnea?

1. Pressure reduction in the colon

We know that pressure in the colon decreases as shown by Vorishlov, A., et al (2017) who used manometry in the sigmoid colon to demonstrate a change in pressure from normal breathing at 2 to 2.5 mmHg to 20.5 to 24.3 mm Hg with Uddiyanha Bandha (hypopressive technique).

2. Pelvic organs lift

Latorre, G., et al., (2011) demonstrated via ultrasound that the pelvic organs “lift” during apnea with the angle formed between the uterus and the vagina changing from 31 to 45 degrees.

Pelvic Cavity Ultrasound

Left Image: Perineal cavity at rest Right Image: inhalation moment when the angle formed between the uterus and the vagina changes from 31 to 45 degrees.

The same study found the angle formed between the urethra and the vaginal wall increases, in effect due to the lift of the bladder with the hypopressive apnea.

Ultrasound Angle formed by the urethra and vaginal wall at rest

Left Image: Angle formed by the urethra and vaginal wall at rest 65 degrees. Right Image: Angle formed by the urethra and vaginal wall increases 12 degrees from 65 to 77 degrees.

3. Muscle Action

Both Latorre, et al., (2011) and Navarro et al., (2017) demonstrated via ultrasound that the pelvic floor muscles (levator ani muscles) achieved elevation, or “lift” without a direct muscle contraction during the hypopressive apnea. Additionally, other researchers have found increased muscle activation in the deep abdominal muscles during apnea. Paterna, C. & Rial, T. (2016) found increased muscle activity in the transverse abdominus muscle and Navarro et al., (2017) and Ithamar et al., (2017) found significantly increased transverse abdominus and internal oblique muscle activation with hypopressive apnea.

The Exercise From Up Above

So with the hypopressive apnea pelvic organs and muscles lift, pressure is reduced, and core muscle activity increases. All indirectly happening from the lift of the diaphragm and associated pressure decrease in the pelvic and abdominal cavities. Wow. Hypopressives have literally flipped Dr. Kegel’s work on its head and are tackling pelvic floor dysfunction from above rather than below!

It’s About Time!

Let’s pause for a moment to consider that this is the first new evidence based exercise technique for treating women’s pelvic dysfunction since Dr. Arnold Kegel developed his eponymous exercises in the 1940’s. Isn’t that crazy to think about?

And as a pelvic floor therapist I can tell you that telling women to “just do your Kegels” isn’t a great solution. In fact that’s why I originally became interested in hypopressives, remember? I had a significant number of women for whom pelvic floor muscle training didn’t work. My older ladies with cognitive impairment and/or pelvic organ prolapse just weren’t seeing the results they wanted with traditional Kegel strengthening exercises. Can you see why I thought hypopressives might be the answer for these ladies? According to the research hypopressives lift pelvic organs and pelvic floor muscles along with automatically activating deep core muscles. Oh my goodness could hypopressives be the magic pill women have been waiting 70 years for?

Not a Magic Pill But a Critical Piece of the Toolkit

The reality is that hypopressives are not a one size fits all solution. This is due to the fact that during the apnea (or any breath holding maneuver such as swimming under water) there is a complicated interplay between the lungs and the heart resulting in heart rate, blood pressure and cardiac output changes. These changes are physiologically normal and well tolerated in a healthy person. But intentionally altering blood pressure and cardiac output in an individual with hypertension or COPD is not a great idea. So many of my ladies in their 80’s and 90s with cardiac and/or lung issues can’t perform the apnea.

What I did discover is that hypopressives are a WONDERFUL option for my healthy patients with pelvic organ prolapse. I’m getting very positive feedback from my patients who are finding reduction in degree of their prolapse, reporting decreased feelings of pressure and discomfort, and improved regulation of bowels. And this intuitively makes sense, right? Wouldn’t women with prolapse benefit from a treatment option of “lifting”?

Now bear in mind I’m not suggesting hypopressives as a treatment option INSTEAD of pelvic floor muscle exercises. Pelvic floor muscle exercises (strengthening or downtraining as indicated) still remain the gold standard treatment for dysfunction. But doesn’t it make perfect sense to add hypopressives to the treatment plan? I think so!

Can I Be Vain For A Moment?

Aside from the use of hypopressives as a therapeutic treatment, there is another reason why they are hugely popular form of exercise worldwide in countries such as Spain, France and Brazil…..

Hypopressive Low Presser Before image

Hypopressive Low Presser After image

These photos were taken about 48 hours apart. No photo editing was done other than the arrows to point out where to look in the pictures. Yes these are photos of me (ugh!) before learning to do hypopressives and then about 48 hours after. No it’s not your imagination. My belly is definitely flatter with skin “lift” and my posture is improved. With hypopressives, in a very short period of time my clients report improved core tone, a flatter belly, improved posture and even decreased lower back pain (5). Globally, women in Spain and Brazil (in particular) have taken to hypopressives/ Low Pressure Fitness for core toning and aesthetic results. I have a Spanish client right now who tells me it’s as popular in Spain as yoga or spin in the US.

The Take Home

I do hypopressives. I feel better and I look better. I’m getting really positive feedback from my patients. We have some very promising studies and a growing body of research that increases almost monthly supporting its use for improving prolapse, incontinence, lower back pain, and improving respiratory parameters. Hypopressives are the latest and could be the greatest. Time will tell. By the way I did reach out to America’s most famous hypopressive practitioner, Arnold Schwarzenegger, to get some feedback on how 50+ years of performing hypopressive exercises is working out for him. I still haven’t heard back. Mr. Schwarzenegger, the women of the US would love to hear your experience……..

References:

References

1) Omkar, S. (2012). Uddiyana Bandha- a Yoga Approach to Core Stability. Sense, 2(2), 112-117.

2) Voroshilov, A., et al (2017). Modified Quigong Breathing Exercise For Reducing the Sense of Hunger on an Empty Stomach. Journal of Evidence-Based Complimentary & Alternative Medicine, doi.org/101177/2156587217707143

3) Rial, T., Pinsach, P. (2016). Low Pressure Fitness Practical Manual Level 1(1st Ed). Vigo, Spain. International Hypopressive & Physical Therapy Institute.

4) Caufriez, M., Fernandez, JC., & Heimann, A. (2007). Comparison Between Abdominal Pressure Variations in Acoustic and Aerial Environment During Four Hypopressive Gymnastic Exercises. Rev Iberoam Fisioter Kinesol, 10(1), 12-23.

5) Bellido-Fernandez, L., et al. (2018). Effectiveness of Massage Therapy and Adominal Hypopressive Gymnastics in Nonspecific Chronic Low Back Pain: A Randomized Controlled Pilot Study. Journal of Evidence-Based Complimentary & Alternative Medicine, doi.org/10.1155/2018/3684194

Ithamar et al. (2017). Abdominal and Pelvic Floor Electromyographic Analysis During Abdominal Hypopressive Gymnastics. Journal of Bodywork & Movement Therapies. doi.10.1016/j.jbmt.2017.06.011.

Latorre, G., Seleme, M., Resende, A.P., Stupp, L., y Berghmens, B. (2011). Hypopressive gymnastics: evidence for an alternative traning for women with local proprioceptive deficit of the pelvic floor muscles. Fisioterapia Brasil, 12(6), 436-466.

Navarro et al., (2017). Muscle Response During a Hypopressive Exercise After Pelvic Floor Physiotherapy: Assessment With Transabdominal Ultrasound. Fisioterapia 39(5): 187-194.

Paterna, C. & Rial, T. (2016). Puede ser el entrenamiento hipopresivo una alternativa de

ejercicio para le reeducacion abdomino-pelvica? Il Congreso Fisioterapia del Movimiento.