Neurourology and Urodynamics 30:15181521 (2011)

Pelvic Floor Muscle and Transversus Abdominis Activation

in Abdominal Hypopressive Technique Through Surface
Electromyography
Liliana Stupp,1* y Ana Paula Magalhaes Resende,1y Carla Dellabarba Petricelli,2 z
Mary Uchiyama Nakamura,2 Sandra Maria Alexandre,2 k and Miriam R. Diniz Zanetti2
1
Department of Gynecology, Federal University of Sao Paulo, Sao Paulo, Brazil
2
Department of Obstetrics, Federal University of Sao Paulo, Sao Paulo, Brazil

Aims: The abdominal hypopressive technique (AHT) is performed mainly via transversus abdominis (TrA) activation
and has been indicated for pelvic oor muscle (PFM) disorders. In some European countries, this technique has become
widely used. This study aimed to investigate PFM and TrA activation during the AHT through surface electromyogra-
phy. Methods: Thirty-four nulliparous physical therapists in good general health were asked to participate in the
trial. To ascertain a correct PFM contraction, each of the participants was assessed by inspection and digital palpation.
Ability to contract the TrA was assessed by surface electromyography and AHT training was given before analysis. TrA
and PFM activity was recorded using surface electromyography. Results: The mean age of the volunteers was 28.1
(
6.0) years and the mean body mass index was 23.7 (
3.3) kg/m2. More than half of the volunteers were physically
active (61.3%) and regularly performed PFM training (52.9%) but not TrA exercises (58.8%). Although the AHT acti-
vates the PFM when compared to resting tone (P < 0.001), this method is signicantly less effective than PFM alone
(P < 0.001). Additionally, the combination of the two techniques (AHT PFM) was similarly effective as isolated PFM
contraction (P 0.586). Although the AHT activated the TrA signicantly more than did PFM alone (P 0.002), the
addition of PFM contraction to the AHT signicantly increased the amount of TrA activation (P < 0.001).
Conclusions: Based on our results, the AHT is less effective than PFM contraction alone, and adding PFM contraction
to AHT also improves the TrA contraction. Neurourol. Urodynam. 30:15181521, 2011. 2011 Wiley Periodicals, Inc.

Key words: hypopressive; pelvic floor muscle; transverse abdominal

INTRODUCTION fundamental questions when evaluating the AHT should be

The pelvic oor muscles (PFMs) form the inferior border of
the abdomino-pelvic cavity, which is delineated by the lum-
bar vertebrae and posterior spinal muscles, the diaphragm,
the abdominal wall, and the PFMs.1 Several studies have
measured the co-activation of abdominal muscles during PFM
contractions in continent and healthy volunteers using differ-
ent EMG methods.25 Variable patterns of abdominal muscle
co-activity occur during PFM contraction. PFM activity has
been reported with the activity of some abdominal muscles,3
selective activation of the transversus abdominis (TrA),4 or co-
activation of the TrA and the internal oblique muscles.5 The
variation in ndings may be due to differences in the contrac-
tion intensity (e.g., submaximal vs. maximal contraction), the
instructions, and the recording methods (e.g., intramuscular or
surface electromyography (sEMG)).6
The abdominal hypopressive technique (AHT), proposed by
Caufriez,7 is performed mainly via transversus abdominis
activation and has been indicated for the treatment of pelvic
oor disorders. In some European countries, such as Belgium
and France, this technique has become widely used. Caufriez
hypothesized that this method relaxes the diaphragm,
decreases intra-abdominal pressure and may activate the
abdominal and pelvic oor muscles simultaneously.7
On the other hand, some authors believe that contraction of
the TrA may increase the intra-abdominal pressure and, as a
result, could negatively impact the pelvic oor by causing
PFM caudal displacement.810
To date, there is no consistent evidence that the AHT is
capable of achieving its intended purposes, including acti-
vation of either the PFM or TrA muscles. Therefore, the
the following: Can this technique improve PFM activation
alone? Could this method replace the PFMT?
To answer these key questions, this study was designed to
investigate PFM and TrA activation during the AHT through
surface electromyography.
MATERIALS AND METHODS
Design
Thirty-four nulliparous female physical therapists admitted
to the medical section of Obstetrics Department of Federal
University of Sao Paulo in good general health were asked to
participate in the trial. The inclusion criteria included willing-
ness to participate in the study and ability to contract the
pelvic oor and perform the AHT correctly. Potential subjects
were excluded in the following cases: if unable to contract
either muscle group correctly; if pregnant; or if diagnosed
Christopher Chapple led the review process.
Conict of interest: none.
y
Postgraduate Student of Department of Gynecology.
z
Postgraduate Student of Department of Obstetrics.
Associate Professor of Department of Obstetrics.
k
Adjunct Professor of Department of Obstetrics.
*Correspondence to: Liliana Stupp, Department of Obstetrics, Federal University
of Sao Paulo, Rua Napoleao de Barros, 875, Sao Paulo CEP: 04024-002, Brazil.
E-mail: liliana.unifesp@gmail.com
Received 12 January 2011; Accepted 14 April 2011
Published online 8 August 2011 in Wiley Online Library
(wileyonlinelibrary.com).
DOI 10.1002/nau.21151

2011 Wiley Periodicals, Inc.


with a known neurological disease, autoimmune connective
tissue disorder or pelvic oor dysfunction. Ethical approval
was granted by the Ethics Committee of the Federal Univer-
sity of Sao Paulo, paper no. CEP 0362/10, approved on April 1,
2010. Subjects completed a short questionnaire about age,
height, weight, and physical activity level.
Testing Pelvic Floor and Transversus Abdominis
To ascertain an adequate PFM contraction, each volunteer
was assessed by inspection and digital vaginal palpation to
observe a lift of the pelvic oor in a superior, anterior direction
and a constriction around the urethra, vagina, and rectum
while in a supine position.11 The patients were requested to
lift and squeeze the PFM as hard as possible. The highest computed RMS value was selected as the maxi-
To test for correct TrA contraction, electrical activity gener-
ated with contraction was evaluated using sensors placed on
the lateral abdominal wall at the level of the umbilicus and
by palpating the inward movement of the abdominal wall
without movement of the pelvis or lower lumbar spine.3,5
Breathing was standardized by giving the following instruc-
tions: take a moderate breath in, let the breath out, and then
contract the TrA.10 After this evaluation, AHT training
consisted of asking the patient to rst do a slow diaphrag-
matic inspiration, followed by total expiration and then grad-
ual contraction of the transversus abdominis and intercostal
muscles with the rise of the hemidiaphragm and apnea.7
Procedure
TrA and PFM activity was recorded using surface electro-
myography equipment with 8 channel module (EMG System
do Brasil LTDATM), which consisted of a signal conditioner
with a band pass lter with cut-off frequencies at 20500 Hz,
an amplier gain of 1,000 and a common mode rejection ratio
of >120 dB. All data were processed using specic software
for acquisition and analysis (AqData). Additionally, a 12-bit A/
D signal converting plate for converting analog to digital
signals with a 2.0 kHz anti-aliasing lter sampling frequency
for each channel was used. The plate used an input range of
5 mV. It has been demonstrated previously that surface EMG
is a reliable method of assessing pelvic oor muscle activity in
healthy women.1217
Surface EMG of the pelvic oor was recorded using a
vaginal probe (Chattanooga Group1), which has two opposing
metal sensors. A reference surface silversilver chloride
electrode (MeditraceTM 133) was positioned on the medial
malleolus. Each volunteer was given privacy in a laboratory
area where they inserted the single-use probe intravaginally,
using a small amount of anti-allergenic gel (KY, Johnsons &
Johnsons1, New Jersey). The probe was positioned with the
metallic sensors placed laterally in the vagina. To standardize
the placement, a mark was made on each probe that was to
face the anterior position. Data collection began once the
subject was able to perform a PFM contraction and the AHT.
With the probe in place, each patient performed the following
three maneuvers in random order while surface EMG data
were acquired: PFM contraction alone, the AHT alone, and the
AHT in combination with voluntary recruitment of pelvic
oor muscles (AHT PFM).
All data were recorded with the subject in a supine position
with a pillow under the head and the thighs slightly abducted.
The resting tone (i.e., the electrical activity of the PFM at rest)
was measured over the course of 1 min.
Surface EMG data were acquired from the TrA muscle using
bipolar pairs of MeditraceTM electrodes. The electrode pairs
Neurourology and Urodynamics DOI 10.1002/nau
Muscle Activation in Hypopressive Technique 1519
were positioned along either side of the course of the under-
lying muscle bers and centered 2 cm cephalic to the pubic
bone, just lateral to the midline, and parallel to the superior
pubic ramus.
The subjects were then instructed to perform three maximal
voluntary contractions (MVC) of the PFM with 30 sec of rest
between contractions. We used the best of three contractions,
which is a reproducible method of evaluation according to
Grape et al.12
The evaluation parameter was the root-mean-square using
the best of the three contractions and a moving-window
technique. Root mean square (RMS) absolute values were
calculated across all contractions using a sequential 200 msec
sliding window in 1 msec increments across each data set.
mum voluntary electrical activity. All evaluations were
carried out at 2-min intervals. Readings were taken from left
and right sides (TrA) and an average was calculated, as there
was no signicant difference between sides (MannWhitney
test, P 0.124).
Statistical Analysis
An analysis of measures was carried out using SPSSTM
(Statistical Package for Social Sciences), version 17.0, manufac-
tured by IBM Company (Chicago, IL). The Wilcoxon Signed
Rank test was used to analyze the possible differences in PFM
and TrA activation between techniques, with a signicance
level of 5% (0.05).
RESULTS
The mean age of the volunteers was 28.1 (
6.0) years, and
the mean body mass index was 23.7 (
3.3) kg/m2. More than
half of the volunteers were physically active (61.3%) and regu-
larly performed PFMT (52.9%) but not TrA exercises (58.8%), as
presented in Table I.
Pelvic Floor Activation
Although the AHT activates the PFM when compared to the
resting tone (P < 0.001), this method is signicantly less effec-
tive than PFM contraction alone (P < 0.001). Additionally, the
combination (AHT PFM) was similarly effective as com-
pared to PFM contraction alone (P 0.586). The analysis of
PFM activation comparing the three studied techniques are
detailed in Table II.
Transversus Abdominis Activation
Although the AHT activated the TrA signicantly more than
PFM contraction alone (P 0.002), the combination of PFM
TABLE I. Background Variables for Study Participants
Variable n 34
Age (years) 28.1 (6.0)a
Body mass index (kg/m2) 23.7 (3.3)a
Number participating in regular physical activity 19 (61.3)b
(>2 times a week)
Number performing regular PFMT (>2 times a week) 18 (52.9)b
Number performing regular TrA training 14 (41.2)b
(>2 times a week)
a
Mean (SD).
b
N (%).
1520 Stupp et al.
TABLE II. PFM Activation in the Three Studied Techniques (Mean and
Standard Deviation)
Variable pairs (mV) Mean SD Sig. (P)
Resting tone 22.90 11.00 <0.001
AHT 47.09 31.09
AHT 47.09 31.09 <0.001
PFM isolated 101.05 44.20
AHT PFM 104.79 50.62
PFM isolated 101.05 44.20
AHT 47.09 31.09 <0.001
AHT PFM 104.79 50.62

P-value calculated using the Wilcoxon Signed Rank test.
contraction and the AHT signicantly increased TrA acti-
vation, as presented in Table III.
DISCUSSION
This study allowed us to investigate the relationship
between PFM and TrA muscle activity by performing the AHT
in healthy, nulliparous volunteers. Our results showed that,
although the AHT activated the PFM compared to the resting
tone, this method is signicantly less effective than PFM
contraction alone. Additionally, the combination (AHT PFM)
was similarly effective when compared to PFM contraction
alone. Although the AHT activated the TrA signicantly more
than did PFM contraction alone, the combination of PFM con-
traction and the AHT signicantly increased TrA activation.
Bo et al.10 evaluated the cephalo-ventral displacement of
the PFM by transabdominal ultrasound during PFM and TrA
contractions, and found results similar to ours. Instructions to
contract the PFM produced signicantly greater displacement
in the cranio-ventral direction than did instruction to contract
the TrA (P 0.002). Displacement during TrA and PFM con-
traction was signicantly higher than with TrA contraction
alone (P 0.003). However, no direct comparison can be
made between the results of studies that have used different
techniques and methods of evaluation. To date, we have not
been able to nd any studies that included AHT evaluation or
treatment for comparison.
Our results did not show any signicant differences
between AHT PFM and PFM contraction alone (P 0.586),
suggesting that the addition of the AHT to PFM contraction
does not produce additional effects. As a result, it seems that
there are no benets to adding the AHT to PFM exercises.
Combining voluntary PFM contraction and the AHT may
be one way to potentiate this technique to increase TrA
activation, as seen in our results.
TABLE III. Transversus Abdominis Activation Comparing the Three
Studied Techniques (Mean and Standard Deviation)
There is some evidence that PFM contraction occurs during
TrA contraction in continent women,2,3,5,10,18,19 but this
co-contraction is lost or altered in some women with urinary
incontinence.10,20,21
It has been suggested that recruitment of the TrA muscles
alone can cause injury to the PFM. If a co-contraction does not
occur, contraction of the TrA opens up the levator hiatus and
pushes the PFM downwards, thus stretching and weakening
0.586 the pelvic oor.10 An increase in the size of the levator hiatus
was found during TrA contraction. During PFM contraction, all
women (n 13) had reductions in all levator hiatus dimen-
sions, while two women had a widening of the hiatus during
TrA contraction, which was visualized by 3D ultrasound.
It is necessary to take potential anatomical changes in the
TrA into consideration when placing electrodes for electro-
myography. Woodley et al.22 described the importance of the
specic arrangement of the motor endplate bands, which are
formed by a collection of neuromuscular junctions. They
revealed that some portions of the abdominal muscles contain
single endplate bands, while others have multiple bands. This
variation probably results from differences in fascicular
length. With respect to the TrA, the fascicles are generally
shorter in the upper and lower parts of the muscle (containing
single endplate bands) but longer in the middle (usually
containing more than one endplate band).
Some limitations of this study should be considered. The
volunteers included in our study demonstrated good compre-
hension of the instructions when the AHT and PFM contrac-
tions were performed, activating the muscles correctly and
when appropriate. Physical therapists may have more intel-
lectual knowledge about both the PFM and TrA muscles than
other study groups.10 For this reason, we cannot expect the
same results from women with different types of pelvic oor
disorders, in whom the pelvic oor musculature, fascia and
nerves may be injured and malfunctioning.
There is a risk of interference from other abdominal
muscles, often referred to as cross talk, during evaluation by
surface electromyography. Hence, the results from all studies
using surface electrodes need to be interpreted with caution.9
Although we found that there is activation of the PFM and
TrA muscles during the AHT compared to the baseline muscle
tone at rest, it seems that this activation is not sufcient to
provide benecial effects in terms of increasing muscle
strength.
There is not a compelling reason to change standard practi-
ces when there is a substantial body of evidence from
randomized controlled trials that shows that the existing
method is sufcient. Implementation of new theories without
previous validation is not recommended.23
CONCLUSIONS
Based on our results, the AHT is less effective than PFM con-
traction alone, and adding PFM contraction to AHT also
improves the TrA contraction.

Variable pairs (mV) Mean SD Sig. (P)

ACKNOWLEDGMENTS
AHT 35.3 16.8 0.002 The authors are grateful for the support received from
PFM isolated 18.8 12.6 Mahle Foundation.
AHT PFM 58.2 39.1 <0.001
PFM isolated 18.8 12.6
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