Breathing and Training the Pelvic Floor

The integration of breathing exercises into pelvic floor muscle training (PFMT) has been a topic of growing interest among physiotherapists, fitness experts, and those affected by pelvic floor disorders (PFD).

The allure of enhancing PFMT effectiveness with something as natural and accessible as breathing techniques is undeniably appealing.

This blog delves into the latest research and systematic reviews exploring the nexus between respiration and pelvic floor muscle functionality, aiming to demystify the potential benefits and limitations of incorporating breathing exercises into PFMT programs.

What we know already…

• Pelvic floor muscle training (PFMT) is highly recommended (grade A, level 1 evidence) for reducing pelvic organ prolapse (POP) and stress urinary incontinence (SUI) symptoms and severity.
• PFMT works well because it's based on how the body is built, how it moves, and exercise science.
• Regular practice improves conditions over time.
• Other studies suggest different exercises might work as well as or better than PFMT for POP & SUI.

Social media often highlights alternative methods like hypopressives and breathing exercises for treating POP & SUI.

Some claims on social media say PFMT doesn't help with POP & SUI, challenging its effectiveness.

Hypopressives, diaphragmatic breathing, and Pilates are all exercises claimed to positively influence the pelvic floor's health and functionality.

Each approach brings a unique perspective to pelvic floor rehabilitation and strengthening.

Hypopressives: This method focuses on reducing pressure on the pelvic floor muscles through a series of postures and breathing techniques. The goal is to activate the pelvic floor and abdominal muscles in a way that's different from traditional exercises that increase intra-abdominal pressure. Proponents claim that hypopressives can help in the prevention and treatment of pelvic floor dysfunctions, such as urinary incontinence and prolapse, by strengthening and toning these muscles without the strain that comes from more conventional core exercises.

Diaphragmatic Breathing: Also known as deep breathing, this technique emphasises breathing deeply into the diaphragm rather than the chest, which can help relax and engage the pelvic floor muscles. Practitioners believe that diaphragmatic breathing can improve pelvic floor awareness and control, reduce stress, and enhance the overall function of the pelvic floor muscles. It's often recommended as a starting point for those new to pelvic floor exercises or as a complementary practice to other pelvic floor strengthening methods.

Pilates: Pilates is a form of exercise that emphasises the body's core strength and stability, including the pelvic floor muscles. It involves precise movements and specific breathing techniques to improve posture, muscle tone, and flexibility. Many Pilates exercises are designed to strengthen the pelvic floor along with other core muscles, providing a more holistic approach to pelvic health. Advocates of Pilates for pelvic floor health argue that it can be particularly beneficial for improving muscle tone, control, and endurance of the pelvic floor muscles.

Evidence based practice or over exaggerated hype?

Delving into the research on hypopressives, diaphragmatic breathing, and Pilates in relation to pelvic floor health unveils a significant layer of uncertainty and debate among professionals.

Although these techniques are widely promoted for their potential benefits, including improved pelvic floor muscle strength and reduced symptoms of pelvic floor dysfunction, the scientific evidence backing these claims is not uniformly conclusive.

Systematic reviews and randomised controlled trials (RCTs) offer mixed outcomes, with some studies highlighting positive effects while others indicate minimal to no significant benefits compared to traditional pelvic floor muscle training (PFMT). This disparity in findings can be attributed to various factors, including differences in study design, participant characteristics, outcome measures, and the subjective nature of some assessment methods. Furthermore, the methodological quality of studies varies greatly, from high-quality RCTs to studies with significant limitations, further complicating the ability to draw definitive conclusions. As such, while there is anecdotal and preliminary scientific support for the influence of these techniques on the pelvic floor, more rigorous, high-quality research is needed to fully understand their efficacy, mechanisms of action, and potential role in pelvic floor rehabilitation.

Limited Evidence for Breathing Exercises: Despite theoretical connections between respiratory function and pelvic floor muscle activity, current research, including RCTs and short-term experimental studies, provides limited evidence that breathing exercises can significantly improve pelvic floor disorders such as stress urinary incontinence (SUI) or pelvic organ prolapse (POP), or enhance PFM variables beyond the effects of traditional PFMT.

Hypopressive Technique's Ambiguous Results: Hypopressive exercises, which integrate deep breathing with abdominal contractions, show mixed results. Only a minority of studies report positive effects on PFD conditions, with significant methodological limitations preventing clear conclusions about the efficacy of breathing as a sole intervention for improving PFM strength and function.

Comparison with Established PFMT Protocols: Research consistently shows that PFMT, without the addition of breathing exercises, remains the most effective method for improving PFM variables and managing PFDs. The addition of breathing exercises to PFMT does not demonstrate any substantial extra benefit and might divert time and resources from proven PFMT practices.

Need for Further Research: The existing body of evidence underscores the necessity for more high-quality RCTs and anatomical studies to conclusively determine the role of breathing exercises in PFMT programs. This would help clarify the potential for these exercises to facilitate meaningful PFM contractions and contribute to the treatment of PFDs. In the realm of pelvic floor health, techniques such as hypopressives, diaphragmatic breathing, and Pilates have been surrounded by both enthusiasm and skepticism.

The evidence gleaned from systematic reviews and randomised controlled trials paints a complex picture. While there are positive anecdotal reports and some supportive experimental findings regarding these methods' effects on pelvic floor functionality, the scientific community has not reached a consensus that definitively tips the balance towards evidence-based practice. The variability in study designs, methodologies, and participant demographics contributes to the challenge of drawing firm conclusions. It's clear that more high-quality, rigorous research is needed to substantiate the claims made about these techniques.

Currently, traditional pelvic floor muscle training (PFMT) remains the gold standard, backed by a substantial body of evidence for its effectiveness in treating and managing pelvic floor disorders. In contrast, hypopressives, diaphragmatic breathing, and Pilates, while potentially beneficial as part of a broader approach to health, cannot yet be heralded as evidence-based practices in isolation for pelvic floor rehabilitation.

Thus, the enthusiasm for these techniques, while understandable given the desire for comprehensive treatment options, may indeed lean towards over-exaggerated hype in the absence of stronger, conclusive evidence. Healthcare professionals should continue to guide their practices by the current evidence while staying open to new research findings. For patients and practitioners alike, the pursuit of pelvic floor health should be a balanced journey, incorporating established methods and exploring emerging techniques with cautious optimism.