The Research Behind Hypopressives

The Abdominal Hypopressive Technique (AHT) was developed in the 1980s in Belgium by Marcel Caufriez as an alternative to traditional pelvic floor muscle training (commonly known as Kegels). He proposed that the technique would decrease intraabdominal pressure and activate the pelvic floor muscles and abdominals. 

In physical therapy, as in all other parts of the health and wellness community, trends come and go as practitioners and patients look to find the newest and most effective (and often most marketable) techniques to address common complaints. In our practice, we try to use the best available peer-reviewed studies and our own clinical experience to weigh the potential benefits of any new (or newly trendy) treatment intervention. Lately, "hypopressives" have become more popular in the United States after enjoying common use in Europe and Canada - are they any better or worse than what physical therapists here have traditionally prescribed?

What we'd like to know:

1. How is AHT different than traditional pelvic floor contractions?

AHT is based on using negative pressure (a vacuum) to draw the pelvic floor and abdominal muscles upward and inward. First, the practitioner breathes in fully and then exhales completely. Once all air has been exhaled, they hold their breath and open their rib cage "pretending" to take a breath. This position is held for several seconds and then released with an inhalation. 

In a traditional pelvic floor muscle contraction, the person exhales and draws the pelvic floor muscles up and in, while gently co-contracting the lower abdominals.

2. Can AHT strengthen the pelvic floor?

Two studies have shown that both AHT and traditional pelvic floor training were effective in causing a pelvic floor muscle contraction (Resende 2012) and strengthening the pelvic floor (Stupp 2011). 

A more recent study used ultrasound to visualize the contraction of the pelvic floor muscles during AHT, pelvic floor muscle contractions, and then with the two techniques combined. It showed that while a traditional contraction caused the muscles to contract, AHT did not cause a statistically significant contraction. This led to the authors' conclusion that AHT does not strengthen the pelvic floor (Resende 2016).

3. Is AHT more effective at strengthening the pelvic floor than the traditional method?

Both studies showing that AHT could strengthen the pelvic floor also found that traditional pelvic floor exercise was significantly more effective (Stupp 2011, Resende 2012).

4. Does adding AHT to traditional pelvic floor training enhance its effect?

In the ultrasound study, AHT combined with a traditional contraction did not cause more contraction than the traditional method alone (Resende 2016).

This finding is supported by the two clinical studies that showed the pelvic floor muscle activation with the methods combined was not more effective than doing the pelvic floor muscle training in isolation (Stupp 2011, Resende 2012).

 

What should we take away from this research?

As PTs who treat new parents we understand that time, energy, and resources are at a premium. When choosing which exercise modality to perform for postpartum rehab, we try hard to recommend the strategies that we know will be the most effective and safe for our patients. Based on this research, pelvic floor strengthening as we understand it remains the most effective and efficient strategy for muscle retraining. A new article in the British Journal of Sports Medicine summarizes this opinion by stating, "[...}to date, the AHT lacks scientific evidence to support its benefits. At this stage, the AHT is based on a theory with 20 years of clinical practice. We conclude that at present, there is no scientific evidence to recommend its use to patients." (Martin-Rodriguez, Bo 2017).   

Furthermore, the coordination of breath and deep core muscles performed in traditional strengthening is the most functional to use during the motions involved in childcare, etc. Would you try to lift your baby out of a crib while holding your breath and expanding your rib cage? We'd rather train for strength and function at the same time, and work to both rehabilitate and prevent future injuries.

We will continue to recommend traditional pelvic floor strengthening techniques for those clients for whom it is appropriate (most often those with urinary leaking, vaginal heaviness, and back pain). Like any exercise, pelvic floor contractions can be appropriate and recommended for some patients and inappropriate for others; if you are experiencing painful intercourse, constipation, tailbone pain or other signs of pelvic floor muscle overactivity, we recommend an evaluation with a pelvic floor specialist before beginning a pelvic floor strengthening program. 


Resende et al. Can Abdominal Hypopressive Technique Change Levator Hiatus Area?: A 3-Dimensional Ultrasound Study. Ultrasound Quarterly. 32(2):175–179, Jun 2016.

Stupp et al. Pelvic floor muscle and transversus abdominis activation in abdominal hypopressive technique through surface electromyography. Neurourol Urodyn. 2011 Nov;30(8):1518-21. doi: 10.1002/nau.21151. Epub 2011 Aug 8.

Martin-Rodriguez S, Bo 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

What is a Pessary?

While a pessary can look and sound intimidating (or weird, or downright scary), it's an important tool for many women to reduce pelvic floor symptoms and allow them to safely become more active. 

The most common reason that we recommend a pessary for our patients is to address symptoms of vaginal heaviness and/or urinary or fecal leaking caused by pelvic organ prolapse. Prolapse is a condition in which one or more of the pelvic organs (bladder, uterus, and rectum) collapse towards the vaginal opening and cause a bulge in the vaginal wall that you can see or feel. This is often due to a lack of passive support from ligaments and connective tissue (something we cannot control in our own bodies) and active support from the pelvic floor (which we can). It occurs in up to 66% of postpartum women (Vergeldt 2015). Pregnancy is the leading risk factor for prolapse, regardless of vaginal or cesarian delivery, because of the stretch it applies to the passive support of the pelvic organs over time (Vergeldt 2015).

It is important to assess the active support to the pelvic organs provided by the pelvic floor, to determine whether pelvic floor muscle strengthening is needed.  Pelvic floor physical therapists also provide education regarding safe exercise and how to engage your deep core muscles appropriately to reduce downward pressure on a prolapse with daily activities - especially childcare! However, for many of our clients who are experiencing symptoms of heaviness or urinary incontinence, we recommend the use of a pessary to improve passive support immediately and reduce long-term issues.

A pessary is fit to each individual by a physician's office, and is often covered by insurance. They are made of medical grade silicone, and can be worn for several days at a time if desired. The most common shape is a ring, which is folded in half to insert and remove and provides outward support against all sides of the vaginal wall. A pessary can take a bit of time to get used to, but by providing this support, it can reduce or eliminate feelings of vaginal heaviness and leaking. 

Recently, over-the-counter versions of bladder supports have become available without a visit to the doctor. Poise Impressa is a disposable, 8 hour use bladder support that is inserted using a tampon-like applicator (sold by US retailers). Incostress is made of silicone and reusable (sold online from a UK-based vendor).

A common question about the use of pessaries is whether using one can reduce or eliminate prolapse in the long term. A study of women with advanced prolapse using a pessary alone showed resolution of more than half of prolapse and urinary symptoms while it was in use (Ding 2016). However, this study was only three months long and the participants were using the pessary consistently during that time. Finally, another study of women with mild to significant prolapse showed that the group using a pessary in addition to pelvic floor muscle training had greater improvement than the group that did physical therapy alone, although both improved significantly (Cheung 2016).

Ultimately, it is unclear about whether using a pessary in the short term can reduce prolapse in the long term if use is discontinued. However, pessaries have been well-established as a safe and effective companion treatment to pelvic floor muscle training for the best results in the short term. We often recommend to our clients that they use a pessary as long as it is comfortable and feels effective in addressing symptoms of heaviness or leaking. If someone is working on building pelvic floor muscle strength and coordination, a pessary can be effective immediately to improve symptoms while muscles are responding to the exercise program. If someone has symptoms throughout the day, wearing a pessary consistently is likely the best option. If symptoms only occur with running, hiking, etc. then often we will recommend at least using the pessary in those situations to reduce the risk of symptoms occurring. 

If using any product (prescribed or over-the-counter) is painful, we recommend discontinuing use and talking to your doctor or pelvic PT. You may be experiencing sensitivity of the vaginal walls due to low estrogen levels when lactating, or muscular dysfunction that can cause pain. You may also need to try a different shape or size of pessary to better fit your anatomy.


Vergeldt et al. Risk factors for pelvic organ prolapse and its recurrence: a systematic review. Int Urogynecol J. 2015; 26(11): 1559–1573.

Ding et al. Changes in Prolapse and Urinary Symptoms After Successful Fitting of a Ring Pessary With Support in Women With Advanced Pelvic Organ Prolapse: A Prospective Study. Urology. 2016 Jan;87:70-5. doi: 10.1016/j.urology.2015.07.025. Epub 2015 Sep 12.

Cheung et al. Vaginal Pessary in Women With Symptomatic Pelvic Organ Prolapse: A Randomized Controlled Trial. Obstet Gynecol. 2016 Jul;128(1):73-80. doi: 10.1097/AOG.0000000000001489.

Returning to Running after Baby

Running is cheap, easy, and gets you outside in fresh air. For many, it's an important stress reliever and cornerstone of their exercise program.

Many of our new moms are tempted to throw on their running shoes right after their six week follow up, but based on research and our experience, we recommend some caution before heading out the door. Not all exercise is the same, so being cleared for all activities at your postpartum checkup often overly simplifies the risks and benefits of how you return to activity.

Running is an activity that requires stability, flexibility, and good coordination of the deep core muscles: diaphragm, abdominals, lumbar multifidi and pelvic floor. A recent EMG study showed that the pelvic floor increases its activity in anticipation of and as a reaction to the heel strike of a stride during running (Leitner 2016). So, doesn't that mean that running will help strengthen the pelvic floor postpartum? Maybe, but what are the associated risks?

Running is also an impact activity which increases intra-abdominal pressure. The peak pressure increase during running is slightly less than what occurs when coughing, but it is cumulatively more total pressure because running is such a repetitive activity and a cough generally occurs only a few times in a row (Shaw 2014). 

The pelvic organs (bladder, uterus and rectum) are both suspended in the pelvis by connective tissue structures and supported from the bottom by a hammock of pelvic floor muscles. These passive and active support mechanisms are the only tools the body has to counteract the effects of IAP on the pelvic organs, so they must be in good working order to withstand the demands of running. 

In general, we ask the following questions before making our recommendation about returning to running:

1. Are you currently experiencing urinary leaking with coughing, sneezing, laughing, lifting, jumping or running? Urinary incontinence indicates deficits in pelvic floor muscle strength, coordination, or both that cannot withstand these increases in pressure. Pregnancy, regardless of birth mode, can weaken the pelvic floor so it produces less force with less endurance postpartum.

2. Are you currently experiencing a feeling of heaviness, "falling out," or bulging in your vagina? These symptoms indicate the likely presence of some degree of pelvic organ prolapse. This occurs in up to 50% of women, and the largest risk factor for prolapse is pregnancy with a vaginal delivery. Prolapse indicates a lack of passive connective tissue support for the pelvic organs that cannot fully withstand the effects of normal daily activities and increases in this pressure.

3. Are you producing milk (breastfeeding or pumping)? The presence of prolactin, which stimulates lactation, suppresses levels of estrogen. Estrogen is essential in the production and remodeling of pelvic connective tissue in the female body, meaning it is an important player in maintaining mechanical strength in these tissues (Zhou 2016). Therefore, lowered estrogen levels while lactating generally correspond with decreased mechanical strength in the connective tissue that supports the pelvic organs (regardless of the activity).

When a postpartum client asks us about returning to running, we have to look at risks and benefits, the patient's current symptoms, and their ultimate goals. In general, we recommend against returning to running until your body has the sufficient strength and support.

It's also important to ease back into running (both in distance and speed) when it is appropriate. Running on soft surfaces is gentler than hard surfaces, and smaller strides create less pressure than longer strides. 

If someone with symptoms of prolapse feels strongly about returning to running, we often strongly suggest the use of a bladder support such as a pessary to increase passive support to the pelvic organs and decrease risk of worsening organ pressure. 

Cardiovascular exercise for conditioning and weight loss can be achieved without as much impact, such as with brisk hill or stair walking, swimming, or stationary cycling. Even doing bodyweight strengthening exercises such as squats, lunges, wall sits, wall push ups, tricep dips, and bridges in a high intensity interval format raises the heart rate and promotes improved metabolism through increasing muscle mass and cardiovascular challenge.

If you aren't sure abut when or how to return to running, it's important to consult a physical therapist or exercise professional specializing in the postpartum body. Feel free to book a phone consultation or in-person evaluation with us for more information!

 


Leitner M, Moser H, Eichelberger P et al. Evaluation of pelvic floor muscle activity during running in continent and incontinent women: An exploratory study. Neurourol Urodyn. 2016 Oct 29. doi: 10.1002/nau.23151.

Shaw J et al. Intra-abdominal pressures during activity in women using an intra-vaginal pressure transducer. J Sports Sci. 2014 Jun; 32(12): 1176–1185.

Zhou L et al. Estrogen and Pelvic Organ Prolapse. J Mol Genet Med 2016. 10:221. doi:10.4172/1747-0862.1000221

The Wide World of Lubricants

Do you have a favorite lubricant? Or is your strategy to grab whatever happens to be at Walgreens that day? Having a good lubricant can increase pleasure for anyone, and at certain times it's even more essential for comfort. 

If a client is newly postpartum, we recommend using lubricant at least with the first couple of attempts at intercourse. The vagina is usually more sensitive during this time, and using a lubricant can improve comfort and decrease anxiety in the moment. Even if you've never needed it before, we think it's good to have one on hand!

If someone is producing milk (either breastfeeding, pumping, or both) estrogen levels in the body are lower than usual. This can produce a state of vaginal dryness and sensitivity that lasts while lactation is occurring. This low estrogen state also occurs (and lasts) after menopause. For some, this dryness is barely noticeable, and for others it is extremely uncomfortable and limits their ability to tolerate intercourse or exams.

If there is noticeable dryness, a personal moisturizer that is used outside of intercourse may be helpful. We often recommend applying coconut oil at the vaginal opening daily as a moisture barrier to help soothe the tissue (read more below under "plant oil based). A topical estrogen prescribed by a doctor can also directly improve tissue hydration during this time. During intercourse, it is also important to have a long-lasting lubricant. 

If you are experiencing discomfort or pain during intercourse and using lubricant resolves it, then continue using it regularly. If the pain does not resolve, it may be at least partly due to muscular tension. If this is the case, please contact a qualified pelvic physical therapist for evaluation.

 

All lubricants are not created equal! Here's a quick primer:

WATER BASED: Most common and affordable, compatible with all birth control/safe sex barrier methods. Most likely to contain preservatives and other irritants.

PLANT OIL BASED: Lasts longer, has a hydrating effect on tissues over time, can be 100% organic. Not compatible with condoms or other barriers made from latex or polyisoprene.

SILICONE: Lasts longest, works in the shower or bath, compatible with all safe sex barrier methods. Not compatible with silicone toys.

Other major characteristics of lubricants to consider:

pH: Vaginal pH is generally a bit acidic, with pH between 3.5-4.5. However, pH changes throughout the menstrual cycle, and with decreased estrogen levels will become less acidic (up to pH of 6-7). Therefore if you are lactating or in menopause and use a more acidic lubricant (lower number), it can cause burning/stinging. 

OSMOLALITY: Basically, the concentration of water vs. other ingredients. A lubricant with high osmolality can cause dehydration and irritation of sensitive vaginal tissues by drawing out moisture. 

GLYCERIN: Avoid products with glycerin, as it can cause yeast overgrowth and has a high osmolality (potential for irritation).

Our favorites:

Organic extra virgin coconut oil (Oils do not have a pH because they do not dissolve in water. However, additives in coconut oil may influence pH and products sometimes test in a wide range. We recommend buying a 100% pure coconut oil to decrease any interactions with vaginal pH.)

Slippery Stuff (water based, paraben and glycerin-free, pH 5.5)

Good Clean Love Almost Naked (water based, vegan and organic, pH 4)

Sliquid Organics Natural (silicone, pH 6)

 

Want even more detail? Here's a great guide to lubricants from Smitten Kitten

 

 

 

Epidurals and Perineal Tearing?

In recent weeks, it seems we’ve been asked this question more and more frequently by our pregnant clients. It’s overwhelming to try to take in all of the information about the risks and benefits of medical interventions during labor and delivery, and even more challenging when there is only a small number of high quality academic studies available to guide our choices.

An individual’s risk of perineal tearing during vaginal delivery is based on a myriad of factors, some under our control (such as birthing position and the use of hands-on perineal support techniques) and others not (such as the size of the baby and speed of delivery).  The choice to have epidural anesthesia is also dependent on a patient’s medical history, personal values and prior experiences, and often the duration and intensity of labor. However, more and more of our clients are basing this choice, at least partially, on whether an epidural will change their risk of perineal tearing with delivery.

Many studies attempt to separate the effect of variables such as the use of an epidural on risk of perineal tearing. The most recent analysis (Pergialiotis 2014) combined the data from 22 studies with a total of 651,934 subjects. Its conclusion was that those with epidural anesthesia had a 1.95 times greater risk of perineal tearing than those who did not. However, another large single study of 61,308 women showed that in its subjects, the increased risk of tearing with an epidural was not present when the analysis controlled for the fact that more first time mothers choose an epidural, and a first vaginal delivery is also more highly associated with perineal tearing. 

Take away: One study shows that epidurals increase the risk of tearing. Another says that the reason more tearing occurs with epidurals is that more first time moms choose epidurals and first vaginal deliveries are already associated with a higher risk of tearing. 

That’s a lot of statistical analysis to digest, but the short story is that, as with many things in medicine, it is almost impossible to draw definitive conclusions. However, we can definitively say that there has not yet been a study that shows that epidurals decrease the risk of perineal trauma with birth - only that it may increase it or not affect the outcome at all. Our advice to clients is to make choices regarding anesthesia based on other important risks or benefits, but to avoid using risk of tearing as the single deciding factor.  

Are Planks Safe?

The internet is a fantastic resource for many of life's questions. However, when it comes to how to strengthen your abdominals when you have diastasis recti (DRA), there seem to be more questions than answers. One of the most common questions our patients ask is whether it is safe to plank with a DRA. 

Like many questions about health and fitness, the answer is "it depends." We should instead be asking ourselves what we're trying to accomplish with a plank, or any other abdominal strengthening exercise.

If a patient comes to us with a DRA, our goal is to improve the ability of the deep abdominal muscles to hold the two sides of the separation together when she moves through her day. Over time, we hope that consistent, appropriate exercise will improve the tension and thickness of the ligament that runs down the middle of the abdomen (the linea alba) to keep the gap closed in the long term. 

With any strengthening exercise, we have to provide a challenge to the muscle we are targeting to cause it to change in strength. As strength improves, the difficulty of the exercise must also increase to provide a new and appropriate challenge. Exercises that are too easy will not cause any increase in strength, and exercises that are too challenging will cause compensations in the surrounding muscles and bypass the weaker muscle we are trying to target. In the case of a DRA, an exercise that is too challenging will cause the person to compensate by holding their breath, bulging their abdominals, and actually widening the separation in the moment. 

A plank is safe for you if you can do it while using your deep abdominals to generate good tension in the linea alba, while breathing and with good form throughout your body. 

So, when a patient comes to us for guidance in a strengthening program to treat DRA, we need to determine whether any exercise (plank or not) is the appropriate challenge. For many, we need to start simply by practicing recruiting the deep abdominals in positions such as hands and knees, sitting, and standing. For others, we start with a plank or even planks with moving arms or legs. The key is determining what their abdominals look like when they are performing the exercise; all of these patients may be equally challenged by their respective exercises but start at vastly different points. 

Most people need an outside opinion on how their abdominals are performing during an exercise, and even using a mirror may help you determine objectively what your body is doing. If you are unsure of which exercises are right for you, we strongly recommend consulting with a qualified postpartum physical therapist or exercise instructor. 

Postpartum Abdominal Binding

Our postpartum clients often ask us about abdominal binders, and whether they are a safe and effective way to regain abdominal function after birth. Many cultures have a long history of abdominal wrapping in the immediate postpartum period; modern products and programs have popularized the practice and advertise it as a way to correct abdominal separation (diastasis recti) that often occurs postpartum. We acknowledge the wisdom and importance of long-standing traditions, but also recognize that some practices are not right for the majority of postpartum moms. 

With a small number of exceptions, we do not recommend this practice for our clients, as it can adversely affect the pelvic floor (and the core in general) and does not show long term efficacy in correcting diastasis. For women following cesarian birth, gentle compression with a Baby Belly Band, snug camisole or high-waisted underwear can be beneficial to reduce soreness and speed healing. However, this compression should be discontinued within the first two months postpartum.

Explaining why this occurs requires an understanding of the “core.” The core is composed of the diaphragm, lumbar muscles, abdominals and pelvic floor, functioning together in one closed system. A good image is one of a soda can – the system is closed, meaning that pressure generated in one location affects other sides of the “can.” If a woman wears an abdominal binder wrapped tightly in the center of the core, it increases pressure upward and downward. The diaphragm is no longer able to expand as far to allow filling of the lungs with air, and pressure is increased downward onto the pelvic floor (the bottom of the can). In most postpartum moms, the pelvic floor is weakened after pregnancy and birth, and many experience urinary incontinence and pelvic organ prolapse. Women with diastasis recti are even more likely to have these symptoms of pelvic floor muscle weakness. If excess downward pressure is generated downward on the pelvic organs (bladder, uterus and rectum), the pelvic floor cannot adequately oppose it. For a woman who is already experiencing urinary leaking, pelvic or vaginal heaviness, or other symptoms of pelvic organ prolapse, wearing a binder will only worsen those symptoms. For women who are not experiencing those symptoms, they may notice them upon wearing a binder.

Simply put, wearing an abdominal binder may change the shape of the abdomen and size of an abdominal separation while someone is wearing it, but it does not actively train the abdominals and pelvic floor in relationship to the core as a whole. For long-term recovery and function, exercise and re-education of the core muscles is the most effective treatment. We recommend working with a physical therapists or exercise professional who specialize in postpartum recovery.

How Big Will My Baby Be?

Are you pregnant and concerned about your ability to birth a "big baby?"

In late pregnancy, ultrasound and other methods are used to try to estimate a baby's size at birth. We hear a lot of our pregnant clients worrying about their ability to birth their baby vaginally, especially those who have been told that their baby may be on the larger end of the spectrum. 

But how accurate are these estimates, and how does the information affect choices surrounding birth?

The medical community generally defines a large baby as over 8lb 13oz. Statistically speaking, fewer than 8% of babies born in the US meet this definition. 

A new study surveying 1,960 new moms found that four out of five of the mothers who were warned that they might have a big baby did not, in fact, give birth to a large infant. However, those mothers were almost twice as likely to have medical interventions such as labor induction, and almost twice as likely to have a planned cesarian birth.

A 2012 study showed that simply being told the estimated birth weight of a baby caused a significant increase in the percentage of cesarian births when all other variables were controlled. 

The American College of Obstetricians and Gynecologists (ACOG) has published guidelines stating that suspecting a large baby is only "rarely" an indication for a planned cesarian birth. These guidelines say that doctors should only offer a cesarian to women with a baby predicted to weigh over 11 lbs at birth.

As we learn more about the role of womens' past experience, fears, and preconceptions on the processes of labor and birth, it's important to recognize the effect of the large volume of information that women receive during pregnancy. While technological advances and the ability to collect more data can be helpful, anxiety regarding a baby's size may influence how an expecting mother approaches vaginal birth or considers elective cesarian birth.