What To Do About Scars from Childbirth?

abdomen active activity belly button
Photo by freestocks.org on Pexels.com

Joanna Hess PT, DPT, PRC, WCS

No one told you that the pain of childbirth doesn’t end with that final push and it doesn’t matter if you had a vaginal or belly birth. If you are the roughly 10% of demigoddesses who delivered without a tear, bless you and your fairy child.* If you are a mere mortal, here are some secrets for post-partum “battle wound” care.

For many mamas, the scars from delivery heal without any intervention. However, in our clinic, we often see hypersensitive or immobile perineal and cesarean scars that affect other parts of the body and can be a reason for the loss of core stability mechanisms, pain with intercourse, and urinary and fecal incontinence.

Scars are the body’s glue and use a complex set of proteins. While scars are never as strong as the original (70% of the original strength), it usually doesn’t cause a problem. The healing process after cutting your finger on that dull knife is the same for a cesarean incision and perineal tear/cut. Immediately after the injury, lots of good inflammation comes into the area to clot and start a loose frame for new tissue to develop. In the first days, collagen and other healing buddies come in to pull the wound together. It’s not particularly organized, but that’s okay because really, priorities are to keep things from getting in. In the next weeks, the collagen fibers will start organizing according to the demands of that particular tissue resulting in a pinkish or red color to the scar. It’s about this time that you can tell if things aren’t going well, namely, the scar shouldn’t be painful. We don’t know for sure why some scars cause problems and others don’t. The best guesses have to do with genetics, tissue tension, hormonal glands, and blood supply. Within 7-12 weeks, not only should the scar not be painful, but it also should move as freely as the tissue around it—without tugging at other places. The scar should be flat and slightly lighter than skin color.

MOVEMENT AND ICE

In the first days, keep good blood flow to the area while managing the pain. For perineal scars, you can work by breathing gently into your pelvic floor and changing your position regularly so that blood doesn’t stagnate in the area. For cesarean scars, working on deep breathing is a safe way to gently move the area without disrupting the healing. You want to keep big movements limited (but really, you’re a mom and movements are a part of life). Use the pain meds as needed so that your muscles continue to function normally. Things like vagsicles (frozen maxi-pads) and support belts can also help with the pain. A regular ice pack for the c-section scar is also a good option. Make sure to place a thin towel between the ice or vagiscles and the skin.

SCAR MASSAGE

At the postpartum six-week appointment, have your physician or midwife check the mobility of the scar. If it is painful or stuck, ask if the scar healed enough to start gentle scar massage. The idea of the scar massage is to give a non-threatening stimulus for desensitizing the area and re-orienting fibers so that the tissue moves freely.

For both the perineal and cesarean scar, if the movement of the scar exceeds pain 2-3/10, start with just desensitization. This can be as simple as tapping the scar or rubbing the scar gently with a towel for 3-5 minutes/day.

For a perineal scar, use a clean finger to slightly push the scar along perineal body up towards the body to create some slack. Then, move the scar away from the center in all directions (north, south, east, west, and in between) to find out which direction is the least mobile. Hold the scar in the restricted direction for 30 seconds. The pain should not exceed more than 2-3/10. Repeat 3-5 more times. You should be able to steadily tolerate more movement within a month.

For a cesarean section scar before 3 months, lift the tissue around the scar in a generous pinch and move the scar up and down, then side to side. Continue along the length of the scar until you find an area of pain or restriction. At this point, spend a little more time and move that area of the scar 10-30 times and keep moving. Again, the pain should not exceed 2-3/10. For a cesarean section scar older than 3 months, you can mobilize the scar in the same movements by direct pressure or skin rolling—up and down, side to side, clockwise and counterclockwise and lifting with skin rolling.

For the new mama, this is easy to incorporate in the precious quiet moments in the shower.

SILICONE

The gold standard of stubborn scars is silicone with or without compression. For hypertrophic scars and keloids in other parts of the body, silicone sheets and gels are the primary non-invasive prevention and treatment. Silicone strips and gels are easily used over a cesarean scar. Silicone is used daily for 12-24 hours for 2-4 months to soften and decreases the height of the scar. The sheets and compression can also help with the hypersensitivity. Because of the proximity to the body cavities, silicone is not advised for perineal scars.

*If you want to try to avoid perineal tearing altogether, ask your birth team to help birth baby’s head slowly and use warm compresses during pushing, stay active during labor, deliver in a side-lying or upright position, and perineal massage in late pregnancy can all help reduce the risk of perineal tearing.

PHYSICAL THERAPY

If you have tried these simple interventions and still find your scar problematic or think your scar is related to pain in neighboring areas, find a women’s health physical therapist to help manage your care. Recent studies show that in 4-8 sessions, skilled physical therapy changes the mobility and thickness of old scars to decrease pain and improve function.

Scar management is widely promoted in post-operative care in orthopedics, plastics, and dermatology—we hope that scar care will soon be standard of care in post-partum care.

 

Joanna practices at our Downtown location

Joanna Lee Hess

REFERENCES

Aarabi S, Bhatt KA, Shi Y, Paterno J, Chang EI, Loh SA, Holmes JW, Longaker MT, Yee H, Gurtner GC. Mechanical load initiates hypertrophic scar formation through decreased cellular apoptosis. The FASEB Journal. 2007 Oct;21(12):3250-61.

Agha R, Ogawa R, Pietramaggiori G, Orgill DP. A review of the role of mechanical forces in cutaneous wound healing. Journal of Surgical Research. 2011 Dec 1;171(2):700-8.

Comesaña AC, Vicente MD, Ferreira TD, del Mar Pérez-La Fuente M, Quintáns MM, Pilat A. Effect of myofascial induction therapy on post-c-section scars, more than one and a half years old. Pilot study. Journal of bodywork and movement therapies. 2017 Jan 1;21(1):197-204.

Huang C, Murphy GF, Akaishi S, Ogawa R. Keloids and hypertrophic scars: update and future directions. Plastic and Reconstructive Surgery Global Open. 2013 Jul;1(4).

Lewit K, Olsanska S. Clinical importance of active scars: abnormal scars as a cause of myofascial pain. Journal of manipulative and physiological therapeutics. 2004 Jul 1;27(6):399-402.

Marshall CD, Hu MS, Leavitt T, Barnes LA, Lorenz HP, Longaker MT. Cutaneous scarring: Basic science, current treatments, and future directions. Advances in wound care. 2018 Feb 1;7(2):29-45.

Meaume S, Le Pillouer-Prost A, Richert B, Roseeuw D, Vadoud J. Management of scars: updated practical guidelines and use of silicones. European Journal of Dermatology. 2014 Jul 1;24(4):435-43.

Seow KM, Huang LW, Lin YH, Lin MY, Tsai YL, Hwang JL. Cesarean scar pregnancy: issues in management. Ultrasound in Obstetrics and Gynecology. 2004 Mar 1;23(3):247-53.

Son D, Harijan A. Overview of surgical scar prevention and management. Journal of Korean medical science. 2014 Jun 1;29(6):751-7.

Wasserman JB, Abraham K, Massery M, Chu J, Farrow A, Marcoux BC. Soft Tissue Mobilization Techniques Are Effective in Treating Chronic Pain Following Cesarean Section: A Multicenter Randomized Clinical Trial. Journal of Women’s Health Physical Therapy. 2018 Sep 1;42(3):111-9.

Wurn LJ, Wurn BF, Roscow AS, King CR, Scharf ES, Shuster JJ. Increasing orgasm and decreasing dyspareunia by a manual physical therapy technique. Medscape General Medicine. 2004;6(4).

Pilates with Kierstin! Kneeling Side Twist

Kierstin Elliot

Exercise: Kneeling Side Twist

Set Up: Kneel on the reformer facing either right or left side of the room with a strap held in both hands. Hands should be directly in front of the sternum, and arms rounded as if holding a big beach ball. Shoulders relaxed, lats slightly engaged, lower abs lifting up and glutes engaged for stability.

Execution: Inhale to prep. Exhale to twist from waist towards foot bar while maintaining fixed upper body posture. Inhale to return back to starting position. Imagine wringing out your waist.

Focus: Obliques and TA, spinal rotation, and pelvic stability. Be sure to keep the pelvis still while twisting from your waist. Your range of motion should only be about a quarter of a pie. Initiate movement with the ribcage, not the arms.

Importance: Core strengthening, spinal mobility, pelvic stability, and overall coordination.

Modifications: If dealing with bad knees, perform the exercise while sitting on the long box. This can also be done standing on the floor with a theraband attached to a doorknob, or standing with free weights.

 

Pilates with Kierstin! Slingshot Lunges on the Reformer

Just in time for your New Year’s Resolutions, here’s another awesome exercise from Kierstin Elliot, Pilates Teacher at Beyond Basics Physical Therapy!

Goal: Strengthen the glutes and balance 

Exercise: Slingshot Lunges on the Reformer

Set Up: Standing on the floor with right foot near foot bar and left foot against the shoulder rest. Keep left knee straight and tilt upper body forward creating one long diagonal line from head to back toes. Use one blue spring as resistance. Belly button and chin are tucked in with neck lengthened and shoulders rounded back.

Execution: Inhale to send pelvis back into lunge bending the front knee 90 degrees while reaching arms forward and keeping the pelvis level and squared off to the front. Keep shoulders away from ears. Exhale to straighten the front knee, lower arms to sides, and return to your starting position.

Focus: Be sure to keep proper alignment throughout the spine. Lumbar spine should be elongated and supported throughout the entire exercise. Maintain core connection by dropping bottom ribs towards the top of your hips bones. Hips should also be level and squared off to the front- make sure there’s no pelvic rotation during lunges.

Importance: One of the best exercises for strengthening your glutes! This exercise also enhances your ability to stabilize the pelvis and lower back while connecting to the core for improved balance.

Modifications: Limit the range of motion in standard position, or drop back knee to the carriage. Dropping the back knee may draw more focus to the quad, making the exercise feel more like a stretch, however, the focus should still be held on standing glute. For an added challenge, grab a set of 3 pound free weights for your arms for added core control.

Pilates Move of The Month with Kierstin! Lat Pull and Triceps

Kierstin Elliot

kierstinbbpt_sm

Goal: To IMPROVE Posture!

Exercise: Lat Pulls and Triceps

Set up: Lie facedown on the box with naval pulled up towards the spine, chin tucked in with neck lengthened (as if you are holding a tangerine under your chin), glutes engaged, and legs extended. Pull yourself to back bars of the reformer and hold onto the poles with both hands. Use one blue spring for resistance.

Execution: Inhale to lengthen elbows, exhale to bend elbows.

Focus: The main muscle group targeted here are the lats. Think about pulling down from the armpits while the elbows bend and extend. This action will help stabilize the shoulders, keeping them out of the ears. Also, focus on releasing the upper traps and lengthening the back of the neck. The more work we can get from underneath the shoulder blades, rather than above, the better!

Importance: Improves posture! Strong back extensors lead to better posture, especially in this day in age where phones and computers are constantly pulling our shoulders forward and weakening our backs. Incorporate a few lat pulls into your routine and feel taller almost instantly!

Modifications: To make it easier, drop tension to one yellow spring. To make it harder, place a squishy ball between ankles and add hamstring curls or pulses between lat pull sets!

Here I am, demonstrating the lat pull!

A Holiday Gift for You! BBPT is Offering Free Consults for People Living in the Greater NYC Area!

Group Serious 2

Any persistent pain or chronic back or pelvic pain can be tough. It is tough to have and often times it can be extremely isolating. Many of our patients have to go through a number of clinicians before they even get a diagnosis of pelvic floor dysfunction. If you are reading this blog, you probably have some questions about pelvic floor dysfunction and if physical therapy is right for you.

We are here to help. If you are living in the Greater New York Area and have some questions about orthopedic, sports or pelvic floor dysfunction and if physical therapy is right for you, I encourage you to call our office. For a limited period of time, we are offering free 15-minute phone consults with our licensed physical therapists to patients in the greater New York Area. For those of you living outside this area, a fee may apply to the consult but can be applied towards payment for a PT visit if you chose to visit us. Don’t miss this opportunity to learn more about your pelvic floor and what PT can do for you.

The Physical Therapists at Beyond Basics also treat orthopedic (sport and joint injuries), pediatric pelvic floor dysfunction and orthopedic injury, and much more. Give us a call to discuss how PT can help with any one of these issues!

All the best,

Beyond Basics Physical Therapy

212-354-2622 (42nd Street Location)

212-267-0240 (William Street Location)

Life After Giving Birth: Trying to Get Back to Competing After Pelvic Girdle Pain (PGP)

Note from Fiona McMahon PT, DPT

In this blog, our guest writer is talking about pelvic girdle pain (PGP), which can often get confused with pelvic floor dysfunction (PFD), although they are related, they are different conditions. For pelvic floor dysfunction, we often caution against just strengthening the pelvic floor. Often times the pelvic floor muscles are over tightened and tense and strengthening often can worsen the situation. Pelvic girdle pain refers to issues around the pelvic bones and sacrum. Both can occur during pregnancy but often require different treatment approaches. If you have pain, come see us at BBPT.

ball court design game
Photo by Pixabay on Pexels.com

 

Exclusively written for BeyondBasicsPTBlog.com

By: AvaFreya

Back in college, I used to be an avid tennis player and even had the chance of representing my school in intercollegiate tournaments. I would wake up at 5 am for three-hour training sessions all the while trying to balance my studies. But after college, the corporate life sucked me in, and I was lucky if I got to play for an hour every other week.

Then after childbirth, my life consisted of trying to raise a beautiful baby boy. I haven’t picked up my racket in months. It’s not because I don’t have time for things other than raising my child – I’ve been blessed with a husband who assumes his fair share of the responsibility. What’s holding me back is my physical state. The pelvic girdle pain (PGP) I experienced during pregnancy never really went away postpartum. In truth though, it is not uncommon. The American Physical Therapy Association notes that many women continue to have the symptoms of PGP after birth.

It’s a scary thought not to be able to do something you used to love so much. Compared to other stories I’ve heard, my case can be considered mild, but I had to seek help if I wanted to play again. Beyond Basics Physical Therapy led me to Pilates and I learned to channel my breathing in a way that it gently engages my pelvic floor [ remember this may be appropriate for PGP but not necessarily PFD]. It has been a great way to reintroduce strength to my core, considering that pregnancy has changed my body in more ways than one. When I get nostalgic and look at pictures from my glory days, I barely recognize myself. Where are the muscular legs, rock hard abs, and enviable arms? Not in this 34-year-old body of mine, that’s for sure. But I’m committed to gaining control over my body and getting back to the court.

But in the five months that I’ve been doing painstaking therapy, my sacroiliac joint feels a lot better, and I no longer feel stiff. During my recovery, Serena Williams was a great inspiration to me. For one, she’s a fantastic player, and Coral identified her as the highest paid female tennis player. More importantly, though, she’s a mom who never used her pregnancy as an excuse not to get a hold of her life. She probably even went through the same pain many other women, and I did. When I was bed-bound during my pregnancy, my idol was playing in the Australian Open while she was 8 weeks pregnant and even won the final.

Not all women’s bodies are the same or even experience pain similar to mine, but Williams continues to be my inspiration on and off the court. I have been playing tennis with my trainer—sometimes with my husband—and we sometimes play for as long as my stamina allows it. Torquing my hips doesn’t worry me anymore, in fear of a sudden crack of my bones anymore. On excellent days, I think that my backhand is even returning. Although I suspect that it will be a long time before I regain the level, I was playing at during college

Note from Fiona McMahon, PT, DPT at Beyond Basics Physical Therapy

We are so grateful to have AvaFreya share her experience of returning to tear up the court post baby! Everyone’s story evolves so differently with pregnancy and childbirth, which is what makes it both terrifying, exciting, and momentous, all the same time. The truth is some women bounce back on their own, (lucky duckies), others find it to be much more complicated. We recommend coming to visit a Pelvic Floor Physical Therapist during pregnancy and after you give birth to guide you to a program that is right for you. We often run into women, who with the very best of intentions, started down a path that actually made them worse! Often times we see this with women doing excessive Kegels when their pelvic floor is already too active secondary to weakness somewhere else in the body. Frankly, it’s a total bummer and delays getting back to the things you love. If you have recently had a baby or are currently preggers, you owe it to yourself to see a pelvic floor physical therapist who can advise you on exercises to do on your own or treat you more intensively if you need it. Your time and your health are way too precious.

 

For more reading on pregnancy and pregnancy-related conditions, please check out these blogs:

 

Stop Doing Kegels: Real Pelvic Floor Advice For Women (and Men)

Sacroiliac Joint Dysfunction

Lace up or Feet up? Running During Pregnancy

Why Do I Still Look Pregnant?!: Diastasis Recti, Part I

Why Do I Still Look Pregnant: Part II

Mind the Gap: Diastasis Recti Abdominis and What We Don’t Know: Part I

Mind the Gap Part II: Improving the Look and Function of the Mommy Tummy (Diastasis Recti)

 

 

 

We have offices in both midtown and downtown locations. If you recently have had a baby or are pregnant, please give us a call at

 

212-354-2622 (Midtown)

 

212-267-0240 (Downtown)

 

We are offering free phone consultations in both locations for a limited time!

 

 

Hypo-ed up? The use of Hypopressive Abdominal Exercise in Pelvic Floor Dysfunction

balloons

Joanna Hess, PT, DPT, PRC, WCS

I’m a recent transplant to NYC. For the last four years, I was living abroad and working at a interdisciplinary sports hospital. I loved learning about physiotherapy culture around the world. We each had different contributions – the Greek wheel, Scandinavian eccentrics, Australian pain science, and Spanish hypopressives. Hypopressive exercises were magic exercises that helped resolve low back pain, prolapse, incontinence, and diastasis recti abdominis. So of course, I wondered, “Are Americans missing the boat?”

What are hypopressive exercises? And how do they work?

Hypopressive abdominal exercises (HAE) were developed by Marciel Caufriez as a response to the obsession with “the core” and the corresponding exercises (primarily crunches) that would increase downward pressure. Hypopressive abdominal exercises use a pressure gradient between the thorax (the upper part of your trunk) and abdominal cavity to create a “vacuum” effect. By creating a vacuum that draws pressure upward, your body automatically recruits transverse abdominis (TrA) and pelvic floor muscles (PFM). Both the PFM and TrA are core muscles and are important in many functions. The HAE sequence begins with static positions and progresses to dynamic and difficult movements. The set up for the exercise is:

  1. Three breaths filling the ribs making sure the sides are expanding.
  2. Breathe in focused on expanding ribs out and lower ribs up while minimizing belly movement.
  3. Then, breathe out working on spinal elongation and keeping ribs up and out. Hold the exhale for creating the vacuum and relaxing the diaphragm. The belly button should start to move up.
  4. Close the throat as if you were at the end of a swallow to lift, expand, inflate rib cage further increasing the vacuum and pressure differential—like an inhale, but without taking in air.

In diaphragmatic breath, inhalation causes the diaphragm to descend which increases intra-abdominal pressure and a reflexive eccentric contraction of the pelvic floor and abdominal wall(an eccentric contraction occurs when the muscles lengthen). Exhalation is a passive return to the diaphragm’s resting position and if it is a complete exhalation, the PFM and TrA will also contribute some activity. For the hypopressive vacuum, inhalation relies on upper chest and neck muscles instead of the respiratory diaphragm and intercostals (rib muscles). The inhalation lifts the rib cage up and gives more volume. The exhalation activates the PFM and TrA to compress the abdomen which increases the pressure of the abdomen. The pressure difference between the diaphragm is augmented by the closed inspiration and creates the vacuum that creates this automatic response. With HAE, the abdominal cavity has the same increase in pressure, possibly more, than with diaphragmatic breath, but because of the suction upwards, it feels like a different pressure.

What’s the relationship between hypopressive exercises and core coordination?

As measured by surface electromyography (EMG) and dynamic ultrasound, HAE consistently have comparable or less activation of the pelvic floor muscle and transverse abdominis than isolated, well-cued exercises (1-4). However, to increase TrA contraction, HAE with pelvic floor muscle contraction recruits more fibers more than pelvic floor contraction alone (4). HAE biases activation of deeper stabilizers–transverse abdominis, internal obliques, and pelvic floor over the more superficial rectus abdominis and external obliques(6). No research has evaluated the HAE claims of decreased downward abdominal cavity pressure. While HAE are progressed with consideration for increasing challenge, they are not incorporated into everyday positions which has an impact on the body’s ability to integrate into a task.

So, will hypopressive exercises fix my problems?

The solution for downward pressure gone wrong is not forcing upward pressure, but addressing why the body lost its adaptability for life’s demands. I rarely use hypopressive abdominal exercises as treatment for problems of the pressure system–pelvic organ prolapse, stress incontinence, diastasis recti abdominis, lumbar disc herniations, and ventral hernias. Studies show that HAE do not have an advantage over conventional TrA and PFM exercises (8) in losing postpartum weight (9), improving pelvic organ prolapse symptoms (2,4,5), or correcting diastasis recti (10).

Besides being less effective than conventional exercises for strengthening and symptom relief, HAE exchange downward and outward pressure for upward pressure and compensatory muscle patterns. This could show up as gastroesophageal reflux disorder (GERD), hiatal hernias, hyperinflated lungs with increased sympathetic drive (and immediate lightheadedness), restricted diaphragm, forward neck posture, or thoracic outlet syndrome. The respiratory diaphragm has a mechanical advantage for respiration over upper chest and neck muscles which have other postural functions.

Escaping gravity is not yet sustainable which means, normal life—breathing, digestion, walking, and laughing—includes downward pressure. If the goal is to decrease pressure on the pelvic floor, lying down with hips elevated, headstand, downward dog, or inversion table—none of these translate into movements of everyday life, but they also do not alter the body’s normal respiration and stabilization patterns. “First do no harm.”

If someone is having difficulty isolating the PFM and TrA, I would connect with diaphragmatic breath, vary effort level, try different verbal and manual cues, and modify the relative position of the pelvis to the spine (7). After correcting the mechanical “pressure problem,” I would use HAE if an individual is still having great difficulty identifying the transverse abdominis and over-recruiting the rectus abdominis. But, I then would progress out of HAE to a isolated strengthening progression integrated into functional movements. HAE is also one of many tools that can help in decreasing acute low back pain associated with muscle spasm.

I nod at the centuries of wisdom of yoga that note benefit from hypopressive practices for posture, digestion, invigoration, and automatic recruitment of core stability. But let’s also remember the time-tried basics of a healthy movement-filled lifestyle. As more studies are published, I look forward to learning more about subgroups and larger functional goals for which HAE have benefit. For now, the magic bullet for pelvic floor dysfunction is not hypopressive abdominal exercises. Isolated pelvic floor and transverse abdominis activation may be old-school, but are well-researched with strong support and are overwhelmingly more beneficial than HAE at addressing symptom alleviation and muscle strengthening.

 

Thank you so much for reading our blog, if you think physical therapy can help you. Please give us a call at either our midtown location 212-354-2622 or our downtown location 212-267-0240. We are offering free phone consultations at both offices for a short period!

Joanna Hess is a treating therapist at our downtown location

Joanna Lee Hess

References

1. Brazalez BN, Lacomba MT, Mendez OS, Martin MA. The abdominal and pelvic floor muscular response during a hypopressive exercise: dynamic transabdominal ultrasound assessment. Br J Sports Med. 2018;52(Suppl 2):A22

2. Resende AP, Stüpp L, Bernardes BT, Oliveira E, Castro RA, Girão MJ, Sartori MG. Can hypopressive exercises provide additional benefits to pelvic floor muscle training in women with pelvic organ prolapse?. Neurourology and urodynamics. 2012 Jan;31(1):121-5.

3. Resende AP, Torelli L, Zanetti MR, Petricelli CD, Jármy-Di Bella ZI, Nakamura MU, Júnior EA, Moron AF, Girão MJ, Sartori MG. Can Abdominal Hypopressive Technique Change Levator Hiatus Area?: A 3-Dimensional Ultrasound Study. Ultrasound quarterly. 2016 Jun 1;32(2):175-9.

4. Stüpp L, Resende AP, Petricelli CD, Nakamura MU, Alexandre SM, Zanetti MR. Pelvic floor muscle and transversus abdominis activation in abdominal hypopressive technique through surface electromyography. Neurourology and urodynamics. 2011 Nov;30(8):1518-21.

5. Bernardes BT, Resende AP, Stüpp L, Oliveira E, Castro RA, Jármy di Bella ZI, Girão MJ, Sartori MG. Efficacy of pelvic floor muscle training and hypopressive exercises for treating pelvic organ prolapse in women: randomized controlled trial. Sao Paulo Medical Journal. 2012;130(1):5-9.

6. Ithamar L, de Moura Filho AG, Rodrigues MA, Cortez KC, Machado VG, de Paiva Lima CR, Moretti E, Lemos A. Abdominal and pelvic floor electromyographic analysis during abdominal hypopressive gymnastics. Journal of bodywork and movement therapies. 2018 Jan 1;22(1):159-65.

7. Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Manual therapy. 2004 Feb 1;9(1):3-12

8. Martín-Rodríguez S, Bø 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. 2017 Sep 4:bjsports-2017.

9. Sanchez-Garcia JC, Rodriguez-Blanque R, Sanchez-Lopez AM, et al. Hypopressive abdominal physical activity and its includence on postpartum weight recovery: a randomized control trial. JONNPR. 2017; 2 (10): 473-483.

10. Gomez FR, Senin-Camargo FJ, Cancela-Cores A, et al. Effect of a hypopressive abdominal exercise program on the inter-rectus abdominis muscle distance in postpartum. Br J Sports Med 2018;52(Suppl 2):A21