Actas Urol Esp.

2018;42(9):557---566

Actas Urológicas Españolas

www.elsevier.es/actasuro

REVIEW ARTICLE

Efficacy of hypopressive abdominal gymnastics in

rehabilitating the pelvic floor of women: A systematic
review夽
R. Ruiz de Viñaspre Hernández

Escuela Universitaria de Enfermería, Universidad de La Rioja, Logroño, Spain

Received 23 August 2017; accepted 30 October 2017

Available online 16 October 2018

KEYWORDS Abstract
Hypopressive; Background: Hypopressive abdominal gymnastics has been proposed as a new paradigm in reha-
Pelvic floor muscles; bilitating the pelvic floor. Its claims contraindicate the recommendation for pelvic floor muscle
Pelvic floor training during the postpartum period.
dysfunction Objective: To determine whether hypopressive abdominal gymnastics is more effective than
pelvic floor muscle training or other alternative conservative treatments for rehabilitating the
pelvic floor.
Methods: We consulted the databases of the Cumulative Index to Nursing and Allied Health
Literature (CINAHL), the Cochrane Library, Latin American and Caribbean Health Sciences Lit-
erature (LILACS), Physiotherapy Evidence Database (PEDro), PubMed, Scopus, Trip Database
and Web of Science. We selected systematic reviews, clinical trials and analytical studies that
assessed the efficacy of hypopressive abdominal gymnastics in women. The measured outcomes
were the strengthening of the pelvic floor muscles, the incidence of urine incontinence or
prolapse and symptom remission.
We included 4 clinical trials, whose quality was measured with the PEDro scale.
Results: Hypopressive gymnastics is less effective than pelvic floor muscle training for activat-
ing pelvic floor muscles, achieving closure of the levator hiatus of the anus and increasing pelvic
floor muscle thickness, strength and resistance.
Practical implication: The evidence reviewed does not support the recommendation for
hypopressive abdominal gymnastics for strengthening the pelvic floor either during the postpar-
tum period or outside that period. Pelvic floor muscle training remains the first-line treatment
for pelvic floor dysfunction.
Conclusion: There is a lack of quality clinical trials that have evaluated the efficacy of hypopres-
sive abdominal gymnastics.
© 2017 AEU. Published by Elsevier España, S.L.U. All rights reserved.

夽 Please cite this article as: Ruiz de Viñaspre Hernández R. Eficacia de la gimnasia abdominal hipopresiva en la rehabilitación del suelo

pélvico de las mujeres: revisión sistemática. Actas Urol Esp. 2018;42:557---566.

E-mail address: reruizde@unirioja.es

2173-5786/© 2017 AEU. Published by Elsevier España, S.L.U. All rights reserved.
558 R. Ruiz de Viñaspre Hernández

PALABRAS CLAVE Eficacia de la gimnasia abdominal hipopresiva en la rehabilitación del suelo pélvico
Hipopresivos; de las mujeres: revisión sistemática
Músculos del suelo
pélvico; Resumen
Disfunciones del Antecedentes: La gimnasia abdominal hipopresiva se propone como un nuevo paradigma en
suelo pélvico la rehabilitación del suelo pélvico. Sus postulados contradicen la recomendación del entre-
namiento muscular del suelo pélvico en el posparto.
Objetivo: Conocer si la gimnasia abdominal hipopresiva es más eficaz que el entrenamiento
muscular del suelo pélvico u otros tratamientos conservadores alternativos para la rehabil-
itación del suelo pélvico.
Métodos: Las bases de datos consultadas fueron Cumulative Index to Nursing and Allied Health
Literature (CINAHL), the Cochrane Library, Latin American and Caribbean Health Sciences Lit-
erature (LILACS), PEDro, PubMed, Scopus, Trip Database y Web of Science. Se seleccionaron
revisiones sistemáticas, ensayos clínicos o estudios analíticos que evaluasen la eficacia de la
gimnasia abdominal hipopresiva en mujeres. Los resultados medidos fueron: el fortalecimiento
de la musculatura del suelo pélvico, la incidencia de incontinencia de orina o prolapso o la
remisión de los síntomas.
Se incluyeron 4 ensayos clínicos; su calidad se midió con la escala PEDro.
Resultados: La gimnasia hipopresiva es menos eficaz que el entrenamiento muscular del suelo
pélvico para activar los músculos del suelo pélvico, lograr el cierre de hiato del elevador del
ano e incrementar el grosor muscular, la fuerza y la resistencia del suelo pélvico.
Implicación práctica: La evidencia revisada no apoya la recomendación de la gimnasia abdom-
inal hipopresiva para el fortalecimiento del suelo pélvico ni en el posparto ni fuera de él. El
entrenamiento muscular del suelo pélvico se mantiene como primera línea de tratamiento en
las disfunciones del suelo pélvico.
Conclusión: Faltan ensayos clínicos de calidad que evalúen la eficacia de la gimnasia abdominal
hipopresiva.
© 2017 AEU. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.

Introduction and, in the long term, to increase muscle volume so

Pregnancy and childbirth are consistently associated with
postpartum pelvic floor dysfunction (PFD): stress urinary
incontinence (SUI), mixed urinary incontinence (MUI) or pro-
lapse. In most women, in the first 3 years after birth,
the structures that make up the pelvic floor (PF) progres-
sively recover from the situations of overload, elongation
or stress to which they are subjected during pregnancy
and childbirth. In some cases, recovery is not com-
plete and requires conservative or surgical therapies for
rehabilitation.1
Pelvic floor muscle training (PFMT) was proposed by
Arnold Kegel in 1948 to strengthen weakened pelvic muscles
after childbirth. Since then, the effects of PFMT on the
pelvic floor have been widely studied. There is evidence
that PFMT is effective in the resolution or improvement
of SUI2 and MUI3 and for the conservative management of
pelvic organ prolapse.4 Its practice is highly recommended
in gestation and postpartum,5 especially in women with
instrumental births or macrosomic children and also when
urinary incontinence (UI) persists beyond 3 months after
birth.1 The objective of PFMT is twofold: to learn how to
use the muscles of the PF before and during stress situations
that cause leaks, in order to prevent leaks (coordination)
that it provides a support structure for the pelvic organs
(strengthening).6
More recently, Marcel Caufriez created hypopressive
techniques for the recovery of PF in the postpartum period.
In 1980 he named them ‘diaphragmatic aspiration’. Based
on them, he developed hypopressive abdominal gymnastics
(HAG), which is a global and systemic postural tech-
nique, which involves performing hypopressive abdominal
exercises that combine the respiratory technique with
abdominal contraction maneuvers in expiratory apnea.7
His hypothesis is that it relaxes the diaphragm, it reduces
intra-abdominal pressure and simultaneously activates the
muscles of the abdomen and the PF due to the synergy
between the two.8 This new paradigm holds that SUI is
fundamentally related to the loss of muscle tone, so the
mechanism to which he attributes the effectiveness of
his therapy is the strengthening of the slow contracting
muscle fibers (type I) that contribute tonicity to the PF,
as opposed to the strengthening of the fast contracting
fibers (type II) that provide greater strength and that would
be trained in the PFMT.9 Its creator states that it would
therefore not be a priority to perform PFMT after child-
birth, which contradicts the recommendations of scientific
associations.1,3,10,11
Efficacy of hypopressive abdominal gymnastics in rehabilitating
Both PFMT and HAG are currently proposed as rehabili-
tation therapies for the PF, not only during the postpartum
period, but also throughout a woman’s life.
In order to discover the scientific evidence supporting
the recommendation of HAG, this review aims to answer
the following questions:
1. Is HAG more effective than PFMT or other alternative
exercises in improving women’s PF muscle function?
2. Is HAG more effective than PFMT or alternative exercises
for the prevention or rehabilitation of UI or prolapse in
women?
Methods
Eligibility criteria
• Types of studies: studies that evaluate efficacy.
• Systematic reviews with or without meta-analysis.
• Experimental studies, including randomized and non-
randomized clinical trials.
• Observational analytical studies (cohort or case-control).
• Participants: women over 16 years old who are healthy or
have PF dysfunctions (UI or prolapse).
• Type of intervention:
• HAG exercise program.
• Comparisons:
• PFMT exercise program.
• Other physical therapies (Pilates, yoga, Paula method,
postural re-education or other alternative exercises).
• No treatment.
• Type of outcome measures:
• Muscle function:
• Increased volume of the PF muscles.
• Increased strength, endurance, tone, or activity of the PF
muscles.
• Prevention of SUI, MUI or prolapse:
• Incidence or prevalence.
• Rehabilitation of SUI, MUI or prolapse:
• Improvement or recovery rates.
• Improvement of signs and symptoms.
• Improvement of the quality of life.
Sources of information
We searched the term ‘hypopressive*’ without limit in
CINAHL, Cochrane Library, LILACS, PEDro, PubMed, Scopus,
Trip Database and Web of Science. We consulted the articles
published in these bases by the creator of the HAG ‘Caufriez
M*’ in the authors’ field. We also consulted in the databases
all the systematic reviews of the last 5 years on the effec-
tiveness of conservative treatment through the exercise of
PF dysfunctions, with the term ‘pelvic floor’ OR ‘pelvic floor
muscle’ (Table 1 ).
Finally, the articles were handsearched to locate other
studies that had not appeared in the initial search.
The search was conducted between October 2016 and
May 2017. The last search was on 30th May 2017 (Fig. 1).
559
Validity assessment
The validity of the clinical trials was measured using the
PEDro scale. In this scale, external validity is assessed on
the basis of a single criterion, eligibility, but this criterion
does not compute to rate methodological quality and risk
of bias, which is based only on the 10 criteria defined to
measure internal validity. A point is given to each criterion
(random assignment, hidden assignment, blinding of the
therapist, blinding of the assessor, adequate follow-up
[≥85%], intention to treat, comparison between groups and
point estimates and variability). The score ranges from a
minimum of 0 to a maximum of 10. The PEDro scale is a
reliable, valid and comprehensive instrument for assessing
methodological quality.12
Results
Selection of studies
The electronic search with a very broad, unrestricted
term that included all possible names for the technique
(hypopressive abdominal gymnastics, hypopressive gym-
nastics, hypopressive exercises, hypopressive abdominals,
hypopressive abdominal technique or hypopressive) iden-
tified 7 clinical trials on the effect of HAG in PF. The
search of articles published by Caufriez did not show any
results. Among the systematic reviews only one evaluated
HAG (Table 1).
Excluded studies
We excluded the abstracts of the oral presentation of 2 clin-
ical trials and the systematic review.
One trial,13 presented as a not-discussed-poster at the
6th Annual Meeting of the International Association of Urog-
ynecology in Lisbon (Portugal), studied 8 healthy young
volunteers (26.5 ± 5.57 years) without PF dysfunction. Four
women were assigned to the PFMT group and four to the HAG
group, without randomization or blinding, and both groups
had 10 sessions of physiotherapy. The intensity of the CVM of
the PF and the electromyographic activation of the PF mus-
cles before and after training were measured. The PFMT
group significantly increased the number of CVM, and the
HAG group increased the time it maintained symmetry of
contraction. The authors concluded that the combination of
these techniques could achieve a greater activation of the
PF.
Another oral presentation14 shown at the annual meeting
of the International Association of Urogynecology and the
International Continence Society in 2010 in Toronto, Canada,
provided a summary of the results of a clinical trial that was
published 2 years later. This article15 was taken into account
for this review.
The objective of the systematic review16 was to deter-
mine whether other exercise proposals, including HAG, were
more effective than PFMT in the treatment of SUI. The
authors of this review found no randomized clinical trials
of HAG.
560 R. Ruiz de Viñaspre Hernández

Table 1 Databases and search strategies for articles on the effectiveness of hypopressive abdominal gymnastics.

Studies on hypopressive abdominal gymnastics

Databases Terms and search strategy Results Selected articles

CINALH Hypopressive* 6 Resende et al., 2016
Cochrane Hypopressive* 13 Resende et al., 2016
Library Bernardes et al., 2012
Resende et al., 2012
Stüp et al., 2011
Bertotto et al., 2011
Resende et al., 2010
LILACS Hypopressive gymnastics 4 Bernardes et al., 2012
PEDro Hypopressive* 2 Bernardes et al., 2012
Resende et al., 2012
PubMed Hypopressive* 8 Resende et al., 2016
Bernardes et al., 2012
Resende et al., 2012
Stüpp et al., 2011
Scopus Hypopressive* 16 Resende et al., 2016
Bernardes et al., 2012
Resende et al., 2012
Stüpp, 2011
Trip Database Hypopressive* 6 Resende et al., 2012
Bernardes et al., 2012
Web of Science Hypopressive* 13 Resende et al., 2016
Bernardes et al., 2012
Resende et al., 2012
Stüp et al., 2011
Resende et al., 2010

Studies conducted by Marcel Caufriez

Databases Search terms Result Selected articles

*
CINALH Caufriez M (author) 6 0
Cochrane Library Caufriez M* (author) 0 0
LILACS Caufriez 0 0
PEDro Caufriez M* (author) 0 0
PubMed Caufriez Marcel (author) OR Caufriez M (author) 5 0
Scopus Caufriez M* (author) 14 0
Trip Database Caufriez 6 0
Web of Science Caufriez M* (author) 13 0

Systematic reviews that compare the effectiveness of physical therapies in the rehabilitation of the pelvic floor in women

Databases Search terms Results Selected articles

CINALH «Pelvic floor muscle» 21 Bø and Herbert, 2013
Limits --- abstract; Date: 2011---2013. Female
Subject Major: --- therapeutic exercise --- pelvic
floor muscles
Cochrane Library «Pelvic floor muscle» in title, abstract, 21 Bø and Herbert, 2013
keywords, year from 2011 to 2017
LILACS Pelvic floor muscle 129 0

PubMed ((«Pelvic Floor » [Mesh] OR «Pelvic Floor 80 Bø and Herbert, 2013

muscle» [Mesh]) AND rehabilitation))
Review, published in the last 5 years, humans,
female, adult: 19+ years
PEDro Body part: Perineum or genital-urinary system. 58 Bø and Herbert, 2013
Subdisciplines: continence and women’s health
Published since: 2011
Efficacy of hypopressive abdominal gymnastics in rehabilitating 561

Table 1 (Continued)

Studies on hypopressive abdominal gymnastics

Databases Terms and search strategy Results Selected articles

Scopus Pelvic floor muscle 167 Bø and Herbert, 2013
Limits: 2011---2017. Languages: English, French
and Spanish. Areas medical, nursing and others
health professions. Review
Trip Database Pelvic floor. 62 Bø and Herbert, 2013
Limits: 2011---2017. Review
Web of Science «Pelvic floor muscle». Limits: review. 52 Bø and Herbert, 2013
2011---2017

Studies on the effect of HAG in the PF of women

Hypoppresive Caufriez M Pelvic floor muscle: SR

25 articles 0 articles 7 articles

9 repeated
articles

6 articles 1 article

2 excluded 1 excluded
articles article

4 articles

Figure 1 Studies on the effect of HAG in the PF of women. Flow chart of the search process and selection of review articles. SR:
systematic review.

Included studies One trial17 with 34 physiotherapist women without PFD

Finally, four clinical trials were part of this review (Table 2).
Based on the PEDro scale, its internal validity was rated
between 5 and 6 points. Given the characteristics of the
technique evaluated, the blinding of the patients and the
therapist was impossible, so the maximum achievable score
was 8 points for this scale.
Researchers from the Department of Gynecology and
Obstetrics of the Federal University of São Paulo (Brazil) par-
ticipated in the 4 studies. Two clinical trials were designed
to measure and compare the effect of PFMT and HAG on
PF in healthy women17,18 and the other two, in women with
grade II vaginal prolapse.10,15,19
compared the activation of the PF musculature that occurs
during an exercise in PFMT, HAG and in the combined
performance of PFMT + HAG. For each participant, the mea-
surements were made at rest and when the 3 different
exercise options were performed randomly. Each type of
exercise was repeated 3 times and the most intense CVM
achieved was taken as the measure. The mean and standard
deviation of the electromyographic activity was: 22.9 (11) at
rest; 47.09 (31.09) with HAG exercises; 101.05 (44.2) with
the PFMT; and 104.79 (50.62) when PFMT + HAG were per-
formed together. Statistical analysis indicated that muscle
activity during HAG exercise was significantly higher than
the one recorded at rest, but significantly lower than the
562 R. Ruiz de Viñaspre Hernández

Table 2 Studies included in the review.

Clinical trials in women without pelvic floor dysfunction

Author/year/country Method/validity Participants Intervention Results Conclusions

Stupp, 2011 Brazil CT 34 healthy Random performance Activity of the pelvic Adding HAG to PFMT
5/10 physiotherapist of 3 exercises of HAG, floor muscles does not improve
and nulliparous 3 of PFMT and 3 measured with muscle activation
women exercises that surface
combine HAG + LEMP electromyography
during the exercises
of PFMT, HAG and
PFMT + HAG
Resende, 2016 Brazil CT 17 healthy and Random performance Measurement of the The HAG does not
5/10 nulliparous of 2 exercises of GAH, hiatus area of the reduce the area of
sedentary 2 of PFMT, and 2 levator ani at rest the levator ani hiatus
women exercises that and during the during its realization,
combine GAH + LEMP exercises of PFMT, while it is
HAG and PFMT + HAG significantly reduced
in three-dimensional during the realization
ultrasound imaging of the PFMT

Clinical trials in women with pelvic floor dysfunction (prolapse)

Resende, 2012, Brazil RCT, simple 58 women PFMT: Series of 8---12 Muscle function: The benefits obtained
blind, 6/10 with maximum PFMT + HAG maximum with the PFMT on the
prolapse contractions: series voluntary strength and
grade II of 8---10 exercises (3 contraction resistance of the
learning sessions and intensity, pelvic floor do not
exercises at home 12 resistance and improve by adding
weeks) muscular activity the HAG to the PFMT
CONTROL:
instructions on
perineal contractions
without a defined
protocol
Bernar-des, 2012, Brazil RCT, simple Transverse area of The muscle
blind, 6/10 the levator ani hypertrophy achieved
muscle measured with the PFMT is not
with greater when the HAG
two-dimensional is added to the PFMT
ultrasound

CT: clinical trial; RCT: randomized clinical trial; PFMT: pelvic floor muscle training; HAG: hypopressive abdominal gymnastics.

one caused by PFMT (p < 0.001). No difference was found
between the activity recorded with PFMT exercise alone
and the combined exercise of PFMT + HAG (p = 0.586). The
authors concluded that HAG was less effective than PFMTs
in increasing PF muscle activity.
Another recent trial,18 with 17 nulliparous, young, seden-
tary women, without PFD, studied the effect of PFMT and
HAG exercises on the reduction of the hiatus area, which is
formed by the 2 branches of the pubococcygeal muscle of
the levator ani surrounding the urethra, vagina and rectum.
The constriction of the levator hiatus affects continence
and the maintenance of pelvic visceral position. The area of
the levator hiatus was measured at rest, or when performing
PFMT, HAG or PFMT + HAG, on the ultrasound image obtained
at rest and while the exercise was being performed.
A physical therapist taught the participants how to do the
PFMT and HAG exercises correctly and he tested their cor-
rect performance. Each participant carried out, randomly,
the 3 types of exercises, 2 times each and with a break
of 30 s between each of the 6 exercises. A gynecologist,
blinded for the operation, measured the area of the levator
hiatus using three-dimensional ultrasound. The average
area in square centimeters was: 12.2 (±2.4) at rest; 10.4
(±2.1) during PFMT; 11.7 (±2.6) with HAG, and 10.2 (±1.9)
with the combination of PFMT and HAG exercises. HAG
resulted in a reduction in the hiatus of 0.5 cm2 , which was
not significantly different from the area measured at rest
(p = 0.227). PFMT reduced the hiatus in 1.8 cm2 and this
constriction was significantly greater than the measure
at rest or during HAG (p < 0.001), but did not differ from
Efficacy of hypopressive abdominal gymnastics in rehabilitating
that found with the combined practice of PFMT and HAG,
which was 2 cm2 (p = 0.551). The authors concluded that,
during the performance of HAG exercises, the area of
levator ani was not reduced in nulliparous women without
PF dysfunction.
We conducted 2 randomized clinical trials15,19 in the
same population of 58 women with grade II prolapse. These
trials defined the method of randomization, were blind to
the examiner and provided data on group comparability
and detailed interventions: PFMT exercises or exercises
combining PFMT + HAG. Daily, for 3 months, the PFMT
group performed 3 series of 8---12 voluntary contractions,
in a lying, sitting, and standing position; each contrac-
tion was maintained for 6---8 s. The group of PFMT + HAG
performed 10 repetitions of hypopressive exercises, in a
lying and standing position, together with the contrac-
tions of the pelvic floor muscles for 3---8 s. The control
group was only instructed to contract the pelvic muscles
with increases in abdominal pressure, without a defined
protocol.
The data evaluated by Resende et al.19 were: the strength
of the CVM measured with the modified Oxford scale, the
resistance defined by the time in seconds of the CVM mea-
sured with vaginal touch, and the muscular activation during
the exercise, which is recorded by surface electromyogra-
phy, at the beginning and end of the interventions. The 2
options for intervention (PFMT and PFMT + HAG) significantly
increased the 3 evaluated parameters: strength, resistance,
and muscle activity (p < PFMT 0.001), which were not modi-
fied in the control group. In the 2 intervention groups, the
strength and activation achieved was similar, but resistance
was higher in the PFMT group than in the PFMT + HAG group
(p = 0.007). The authors concluded that adding HAG to PFMT
did not have any major benefit on PF’s muscle function in
women with grade II prolapse.
The study by Bernardes et al.,15 measured the increase
in the volume of the levator ani muscle (transverse area
of the muscle measured with two-dimensional ultrasound)
in the 2 protocol training groups and the control group. At
first, the measurements of the area of the levator ani muscle
were similar between the 3 groups. After the intervention,
the measure increased from 1.6 (±0.4) to 2.1 (±0.3) cm2
in the PFMT group, and from 1.4 (±0.3) to 1.8 (±0.5) cm2
in the PFMT + HAG group. In both groups the increase was
significant (p ≤ 0.001), but without any difference between
them (p = 0.078). In the control group there was no change:
from 1.5 (±0.3) to 1.4 (±0.3) cm2 (p = 0.16). Both PFMT and
the combination of PFMT + HAG cause similar hypertrophy of
the levator ani muscle.
Discussion
In this review, we wonder whether HAG is effective in
improving muscle function in PF or in preventing or reha-
bilitating PFD in women. Only 4 studies, with acceptable
methodological quality but with important limitations for
the generalization of their results, provide information.
Consequently, the main outcome of this review is the
lack of relevant studies that have evaluated the efficacy
of HAG.
563
Summary of the evidence
In response to the question ‘Is HAG more effective than PFMT
or alternative exercises in improving muscle function in PF?’,
the 4 included studies agree that the muscle strengthening
achieved with PFMT is superior to that achieved with HAG
and that adding HAG to PFMT does not improve the benefit
achieved by PFMT alone. These results are obtained from
two randomized clinical trials in the same group of women
with prolapse and two non-randomized clinical trials in 2
groups of healthy women, with a total sample of 109 women
studied. The 4 studies have selection biases (randomization
or masking) and performance biases (blinding of patients
and therapists). Further randomized clinical trials of high
methodological quality are needed to support these results.
However, the conclusions reached by the authors are com-
patible with the current knowledge of the physiology of the
PF, as reflected in the literature. It is accepted that PFMT
strengthens the muscles surrounding the urogenital hiatus,
and that its voluntary contraction, which is more potent than
the one reflexively achieved, increases urethral closing pres-
sure and prevents the pelvic organs from descending.3,6 It is
logical that direct training of these muscles is more effec-
tive and highly recommended as a conservative treatment in
SUI, MUI or prolapse.20 By contracting the transverse abdom-
inal muscles, HAG may achieve an involuntary or reflex
co-contraction of PF muscles, but this co-contraction shows
a weaker effect on continence than voluntary contraction.21
On the other hand, co-contraction of the PF muscles, which
occurs by the contraction of the abdominal muscles, has
been proven in women with full PF,22,23 but may not occur
when PF24 lesions are present. Bø et al. observe that, in
some women with prolapse, the contraction of the trans-
verse muscle does not lead to the closure of the hiatus of the
levator ani muscle, but rather to an increase in its area.25
The beneficial effect of the contraction of the transverse
abdominal muscles in strengthening the PF in the treatment
of UI has not been clarified yet and leads to discrepancies
among experts.21,26,27
The 4 clinical trials of this review compare the effect of
HAG with that achieved with PFMT, but we have not found
any studies comparing the effect of HAG with other exercises
such as pilates,28 yoga29 or global postural re-education,30
whose efficacy for PF rehabilitation has been studied. These
exercise proposals appear to improve the CV of incontinent
women, although none of these activities has been more
effective than PFMT for PF recovery.16 They also appear to
help women increase their perception of their pelvic mus-
cles and improve their voluntary contraction.28,30 This same
effect of improving proprioception could be achieved by
HAG,31 but we do not know whether more or less than with
alternative exercises.
Regarding the question ‘Is HAG more effective than
PFMT or than alternative exercises for the prevention or
rehabilitation of PFD?’, we have not found any studies
that have evaluated the efficacy of HAG in the prevention
or rehabilitation of UI or prolapse. This lack of clinical
trials on the efficacy of HAG for UI rehabilitation is already
confirmed in the review conducted by Bø and Herbert
in 2013.16 Another review8 reaches the same result: it
informs about the important contradictions found between
564
the postulates of HAG theory and the published litera-
ture. Among these contradictions, it is noteworthy that
there is not enough evidence on the alleged detriment
of traditional abdominal exercises in women’s PF, or on
the benefit of HAG in it. Thus, while the advocates of
HAG advise against abdominal work in hyperpressure,
other authors maintain that, in a healthy woman, the
increase in intra-abdominal pressure secondary to physical
activity, coughing or sneezing, causes a reflex contraction
of the perineal musculature: this co-contraction increases
intraurethral pressure and prevents urine leakage.22,23 This
may explain why regular exercise is a protective factor
against UI. However, the sudden, excessive and continuous
increase in intra-abdominal pressure that occurs in the
professional practice of some high-impact sports may
overcome this physiological compensation mechanism and
justify the higher prevalence of UIs among elite athletes
while competing, but not after leaving the competition.33,34
In addition, the increase in intra-abdominal pressure when
faced with the same physical activity such as jumping,
cycling or Valsalva maneuvers presents a great varia-
tion among women.35 Therefore, although the relationship
between intra-abdominal pressure and its effect on PF is not
clear yet, the recent review by Nygaard et al.,32 concludes
that most physical exercise, even when it increases intra-
abdominal pressure, does not cause injury or dysfunction of
PF, which is inconsistent with the theoretical assumptions of
HAG.
It is noteworthy that, having postulated HAG more than
3 decades ago, as a new paradigm in the recovery of the PF
musculature in the postpartum period, we have not found
any study evaluating its efficacy in this group of women. We
ask ourselves what is the reason for its rapid implementa-
tion in the clinical practice of some health professionals.
We know that most women, whether they practice HAG or
not, experience a significant improvement in their perineal
symptomatology in the first 3 months postpartum.1 Women
who are advised to practice HAG during this period may asso-
ciate their improvement with this practice, although it is yet
to be demonstrated that their recovery is caused by gym-
nastics. However, the practice of PFMT in pregnancy and
postpartum has shown a reduction in the prevalence of PFD
in postpartum.36,37 It has been observed that even in women
with major levator ani injuries are able to contract the mus-
cles of the PF, which would indicate a potential ability of the
uninjured muscle fibers to compensate for the loss of mus-
cle strength at an early stage after delivery.38 In any case,
it is essential to check that they are being correctly carried
out by all women and to establish strategies that favor their
adherence to the exercise.39
Limitations of the review
The search of articles, in different databases and with
broad search strategies, ensures a very low risk of loss of
articles that would have given different results to those
obtained. However, the small number of articles included in
the review, the number of women studied, and the fact that
they were all carried out by the same research group, in the
same physical environment and with 2 very heterogeneous
populations, but with little variability among women of the
R. Ruiz de Viñaspre Hernández
same condition, considerably limits the external validity
of their contributions. We cannot know whether another
methodology to learn the exercises of HAG and PFMT would
have given a different performance and, consequently,
other results. In addition, each article measured different
characteristics of the musculature (strength, resistance,
muscle activation, hiatus area or muscle volume) and they
even used different measuring instruments for the same
characteristic. It would have been desirable that both,
the muscular characteristics observed in the 4 studies
and the measurement methods had been the same in all
of them.
Conclusion
Current scientific research does not support recommending
HAG for the improvement of muscle function in PF or
for the prevention or rehabilitation of UI or prolapse
in women. PFMT should continue to be recommended
during gestation and postpartum, in order to prevent PFD
and as a first line of treatment, during this period and
beyond.
Conflict of interest
The author declares that she has no conflict of interest.
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