Journal of Bodywork & Movement Therapies 24 (2020) 568e574

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

Prevention and Rehabilitation

Exercise regimens other than pelvic floor muscle training cannot

increase pelvic muscle strength-a systematic review
Raquel Henriques Jacomo a, *, Tatiana Reis Nascimento b, Marianne Lucena da Siva c,
Mariana Cecchi Salata d, Aline Teixeira Alves b, Pedro Rincon Cintra da Cruz e,
~o Batista de Sousa f
Joa
a rio de Brasília, Unidade de Reabilitaça
Hospital Universita ~o, Serviço de Fisioterapia Uroginecolo gica SGAN 605, Av. L2 Norte, Zip-code: 70.840-901, Brasília,
DF, Brazil
b
Universidade de Brasília, Departamento de Fisioterapia, Centro Metropolitano, Conjunto A, lote 01, Campus Ceila ^ndia, Zip-code: 72220-90, Brasília, DF,
Brazil
c
Universidade Federal de Jataí, Departamento de Fisioterapia, BR 364, km 195 no 3800, Zip-code: 75801-615, Jataí, GO, Brazil
d rio do Planalto Central Aparecido dos Santos UNICEPLAC, SIGA, Area
Centro Universita  especial n2 Setor Leste do Gama. Zip-code: 72445-020
e rio de Brasília, Unidade de Urologia, Hospital Universita
Hospital Universita rio de Brasília SGAN 605, Av. L2 Norte, Zip-code: 70.840-901, Brasília, DF, Brazil
. Hospital de Base do Distrito Federal, Departamento de Urologia. SMHS Area Especial Quadra 101, Zip-code: 70335-900
f
Universidade de Brasília. Faculdade de Medicina. Programa de Ci^ encias M edicas. Campus Darcy Ribeiro, Asa-Norte Zip-code: 70910-900, Brasília, DF, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Background: Although pelvic floor muscle training is widely recommendedin the literature as the gold
Received 3 May 2019 standard for the treatment of pelvic floor dysfunctions, such as urinary incontinence, interest in other
Received in revised form exercise regimens is increasing. However, it is unknown whether other exercise regimens increase pelvic
15 June 2020
floor muscle strength.
Accepted 28 August 2020
Methods: This was a systematic review of randomized clinical trials found in PEDro, tridatabase,
Cochrane and PubMed on the efficacy of nonspecific exercises, such as Pilates, the Paula method, and
Keywords:
hypopressive exercises, in strengthening pelvic floor muscles in adults without underlying neurological
Pelvic floor
Pelvic floor disorders
disorders and with or without pelvic floor dysfunction.
Exercise movement techniques Results: Seven studies were analyzed, and the results demonstrated that Pilates, the Paula method, and
Exercise hypopressive exercises are ineffective in increasing pelvic muscle strength unless they are performed in
conjunction with pelvic floor muscle training. The protocol was registered in the PROSPERO database
(www.crd.york.ac.uk/prospero/) under the number CRD42019123396.
Conclusion: Considering the available studies, we have concluded that Pilates, the Paula method and
hypopressive exercises performed alone do not increase pelvic floor muscle strength. Pelvic floor muscle
training continues to be the gold standard for increasing pelvic muscle strength.
© 2020 Elsevier Ltd. All rights reserved.

1. Introduction vagina”, urethra and anus; a cranio-ventral movement involving

According to the International Continence Society (ICS), pelvic
floor muscle (PFM) function is defined as the ability to perform a
normal or strong voluntary contraction, with the presence of an
involuntary contraction, resulting in a “circular closure of the
* Corresponding author.
E-mail addresses: contato@raqueljacomo.com.br (R.H. Jacomo), tatianareis.t@
gmail.com (T.R. Nascimento), marianne.lucena@ufg.br (M. Lucena da Siva),
marianacecchi6@gmail.com (M.C. Salata), alinealves@unb.br (A.T. Alves), pc-cruz@
uol.com.br (P.R.C. da Cruz), sousajb@unb.br (J. Batista de Sousa).
the perineum; and an upward movement of the pelvic organs
Abrams et al., 2010. The PFMs are responsible for the support of
organs and viscera, and they facilitate urinary and fecal continence
and sexual function. The pelvic floor consists of a group of muscles
that surround the pelvic region, extending from the pubis to the
coccyx. Damage to the pelvic floor may lead to decreased PFM
strength, thereby causing pelvic floor dysfunctions, such as pelvic
organ prolapse (POP) and fecal and urinary incontinence (UI) (Fitz
et al., 2016; Da Roza et al., 2013; Child et al., 2013).
Systematic reviews of randomized clinical trials (RCTs) conclude
that there is level 1 and grade A scientific evidence demonstrating

https://doi.org/10.1016/j.jbmt.2020.08.005
1360-8592/© 2020 Elsevier Ltd. All rights reserved.
 R.H. Jacomo et al. / Journal of Bodywork & Movement Therapies 24 (2020) 568e574
that pelvic floor muscle training (PFMT) is effective and should be
indicated as first-line treatment for pelvic floor dysfunctions
(Dumoulin and Hay-Smith, 2010). In 1948, Kegel developed exer-
cises that help improve the function of the PFMs and treat PFM
dysfunctions (Kegel, 1948). The efficacy of other types of exercise
regimens in treating PFM dysfunctions is still controversial. Sys-
tematic reviews have concluded that there is a lack of evidence on
the efficacy of exercise regimens other than PFMT in improving the
symptoms of UI (Bo and Herbert, 2013; Lemos et al., 2019).
Exercise regimens, such as Pilates, yoga, the Paula method,
hypopressive exercises, and breathing, postural, and abdominal
exercises, promote the neutral alignment of the pelvis, shoulder
blades and spine (Ferla et al., 2016a). It is believed that a proper
balance in strength among the diaphragm, transverse abdominal,
multifidus and pelvic muscles results in an appropriately directed
load vector that acts on the spine and pelvis. When this balance is
achieved, these muscles stabilize the sacroiliac joint and perineal
musculature (Mohktar et al., 2013; Rocca, 2016). Therefore, there is
synergy between the accessory muscles (abdominal, paravertebral
and diaphragm) and the PFMs. Some non-specific pelvic floor ex-
ercise regimens engage these muscle groups, promoting favorable
biomechanics of the body and PFM strength (Jacomo et al., 2016;
Costa et al., 2003)Abrams et al., 2010.
To evaluate how effective these alternative exercise regimens
are in improving the function of PFMs, a systematic review was
carried out with randomized studies that used at least one of these
exercises (yoga, Pilates, breathing exercises, postural exercises,
abdominal exercises, hypopressive exercises) as a way to improve
pelvic muscle function in people with or without dysfunctions.
2. Methods
2.1. Search strategy
This systematic review was performed in accordance with the
recommendations and criteria described in the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) and the
Cochrane handbook. The protocol was registered in the PROSPERO
database (www.crd.york.ac.uk/prospero/) under the number
CRD42019123396.
2.2. Data sources
For the systematic review, the following databases were
searched on 23 march, 2019: PEDro, tridatabase, Cochrane and
PubMed.The search strategy included selecting keywords based on
medical subject headings (MeSH) and keywords or free terms
(intervention þ outcome) limited to the chosen type of research,
which was randomized clinical trials in this study. There were no
language restrictions. The following keywords were used: (“pelvic
floor” OR “Pelvic Diaphragm” OR “Pelvic Diaphragms”) AND (“Ex-
ercise Movement Technics” OR “Pilates-Based Exercises” OR
“Pilates Based Exercises” OR “Pilates Training” OR hypopressive OR
“Paula method” OR Yoga OR Exercise OR respiration OR breathing
OR posture OR abdominis) AND (“muscle strength”) AND Ran-
domized Controlled Trial [ptyp]. The studies were selected ac-
cording to the Cochrane manual. The authors initially assessed the
titles and abstracts. After potentially relevant studies were selected,
the methodological quality of the full-text versions was indepen-
dently analyzed by two investigators, and disagreements were
resolved through discussions with or arbitration by a third
investigator.
569
2.3. Quality (risk of bias) and assessment of publication bias
Two researchers evaluated the study quality and risk of publi-
cation bias independently by using the PEDro and ROBIS 1 scale and
screening for selective reporting in the clinical trials.
2.4. Type of study and participants
The following inclusion criteria were used for the selection of
the studies: RCTs that assessed the effect of nonspecific exercises on
PFM strength and RCTs whose study population included adults
without neurological disorders and with or without pelvic floor
dysfunction. Studies with specific populations, such as children,
pregnant women, adults who had undergone pelvic reconstruction
surgeries, were excluded.
2.5. Types of interventions
We considered studies that investigated one of the following
alternative exercise regimens: yoga, Pilates, the Paula method,
hypopressive or bodybuilding exercises, and breathing, postural or
abdominal exercises. We considered studies whose main assess-
ment method was electromyographic biofeedback, manometric
biofeedback, a perineometer, a dynamometer, ultrasound and
magnetic resonance imaging, or vaginal/anal palpation. In addition
to studies that met these criteria, studies with the following types
of comparison were selected: intervention versus control, inter-
vention versus PFMT, and intervention plus PFMT versus PFMT.
2.6. Data extraction
All relevant data on the inclusion criteria [(type of study, pop-
ulation, interventions (including the type of exercise), comparison
and results], risk of bias (randomization, blinding and presence of
control group) and results were extracted. A single researcher
extracted the data and a second researcher reviewed the data.
2.7. Statistical analysis
A descriptive and exploratory analysis of the data, frequency,
mean and standard deviation was carried out using Microsoft Excel
version 2010, and the data are presented as the frequencies, means,
and standard deviations.
3. Results
3.1. Selection and evaluation of studies
In our initial search, we identified 377 studies, 25 of which
were identified as duplicate studies and were thus removed; 348
studies remained. After we screened the titles and abstracts, we
excluded 320 studies because they did not include at least one of
the exercises of interest, and 28 articles remained. These articles
were included in a more detailed analysis; 13 of them were
excluded because the intervention presented was ineligible or
because the study did not meet the inclusion criteria. Four studies
were excluded because they did not present PFM strength results
(Liebergall- Wishchnitzer et al., 2012; ; Mina et al., 2015; Pedriali
et al., 2016), and 4 additional articles were excluded because they
were not randomized trials (Sapsford et al., 2001; Steentrup et al.,
2014; Lee et al., 2016; Souza et al., 2017; Ferla et al., 2016b). Thus,
this systematic review included 7 studies (Liebergall-
Wishchnitzer et al., 2005; Hung et al., 2010; Culligan et al.,
2010; Resende et al., 2012; Torelli et al., 2016; Gomes et al.,
2018; Resende et al., 2019).
570 R.H. Jacomo et al. / Journal of Bodywork & Movement Therapies 24 (2020) 568e574
Fig. 1 shows a flowchart of the steps of the study selection
process performed in this systematic review in accordance with the
PRISMA guidelines.
3.2. Studies included in the systematic review
The publication dates of the 7 studies included ranged from
1961 to 2019, and a total of 456 adult patients were included in the
studies, the majority of whom were female.
3.3. Characteristics of the studies included
Table 1 summarizes the main features of the studies included.
Three studies evaluated the effects of Pilates on PFM strength
(Culligan et al., 2010; Torelli et al., 2016; Gomes et al., 2018), one
evaluated the Paula method (Liebergall- Wishchnitzer et al., 2005),
two evaluated hypopressive exercises (Resende et al., 2012,
Resende et al., 2019), and one evaluated abdominal exercises (Hung
et al., 2010). Most studies evaluated problems related to dysfunc-
tional pelvic floor muscles, such as urinary incontinence and pelvic
organ prolapse. Only one article evaluated PFMs in healthy women
(Culligan et al., 2010), and one study was conducted in male par-
ticipants with postprostatectomy urinary incontinence (Gomes
et al., 2018).
Regarding the assessment methods, most of the studies used
MVC tests. Other assessment methods that were used included
bidigital palpation, perineometry and electromyography.
All studies included were randomized controlled trials that
included an experimental group (EG), who performed one of the
types of alternative exercises mentioned, and a control group (CG),
who performed PFMT. Only two studies featured three groups. In
the study by Resende et al. (2012), there was a hypopressive group
(EG), a PFMT group with a specific protocol (CG1), and a PFMT group
without a specific protocol (CG2). The study by Gomes et al., 2017,
Fig. 1. Study flow diagram.
featured Pilates (EG), PFMT with electrical stimulation (GC1), and
PFMT (GC2).
The studies provided information on the characteristics of the
training program and the types of exercises performed, as shown in
Table 1. We also highlighted the outcome measures, time and
duration of the intervention, frequency of exercise (number of ex-
ercise sessions each week), and duration of the sessions.
3.4. Risk of bias in included studies
Fig. 2 shows the characteristics of the included studies and their
risk of bias, and Fig. 3 shows the summary of Risk of Bias: judg-
ments of the reviewer about each item of risk of bias in the included
studies.
According to the Cochrane Collaboration Tool to assess the risk
of bias, in Fig. 2, of the 7 studies, 5 were assessed as low risk of bias
(Gomes et al., 2016; Hung et al., 2010; Resende et al.., 2012; Resende
et al., 2018; Torelli et al., 2015) 1 as a moderate risk of bias
(Liebergall-Wischnitzer et al., 2005) and one as a serious risk of bias
(Culligan et al., 2010).
For the randomized controlled studies, the 7 attributes of risk of
bias were considered as follows:
1. Allocation: The included study was considered to be of low risk
for selection, as the study used random sequence generation
and allocation concealment, such as that of Culling et al. (2010),
which used enumerated, sealed and opaque envelopes for this
purpose.
2. Concealment: The included study was thought to have a high
risk of hiding the participants, since patients previously knew
what therapy they would be undergoing, such as Liebergall-
Wischnitzer et al., 2005, which used numbers in an open
process.
3. Incomplete data on the results: It is concluded that the study
considered to be of low risk was one that presented balance in
the number of patients within groups, little or no loss of par-
ticipants throughout the study and if such effects did not
reverberate in a way that would detract from the statistics, such
as the study by Resende et al. (2012), in which the groups
remained on an equal footing.
4. Selective reporting: A low-risk study was defined as one in
which the study protocol is present and all primary and sec-
ondary outcomes are considered according to what was pro-
posed, such as the study by Torelli et al., 2015, which presents its
study protocol, as well as addresses the previously specified
outcomes.
5. Other potential sources of bias: A study that considered other
biases that did not fit the other classifications was considered
high risk. No study has shown other biases that were outside
these classifications.
4. Discussion
The present study systematically reviewed the literature on
alternative exercises that may indirectly influence pelvic floor
muscle strength. This review analyzed various interventions, such
as Pilates, the Paula method, and hypopressive and abdominal ex-
ercises, and the results suggest that alternative exercise regimens
performed alone do not increase pelvic floor muscle strength.
Of the interventions presented in this review, Pilates was the
most common. Pilates, as well as other therapies, focus on the
activation of the transverse abdominal muscles. According to the
literature, this type of exercise improves the tonus of the abdominal
wall, normalizes the tension in abdominal structures and antagonist
muscles, consequently increasing PFM activation (Ferla et al., 2016;
Table 1
Characteristics of the studies included in the systematic review A: urinary incontinence. B: stress urinary incontinence. C: pelvic organ prolapse. D: postprostatectomy urinary incontinence. MVC: maximum voluntary
contraction. PFMT: pelvic floor muscle training. PE: perineal electrostimulation.

Study Study sample Sample size (n) Age (years) Variables Description of the intervention Frequency Duration of the Duration of the PEDro Outcome
(d/weeks or session (min) program (weeks)
months)

Liebergall- UIA CG M 30 EG M 29 20 to 65 MVC palpation - Paula Method 1 45 12 8 The two groups increased the
Wischnitzer 20 to 65 perineometry 1 30 4 PFM strength in palpation
et al., 2005 - PFMT There was no difference

R.H. Jacomo et al. / Journal of Bodywork & Movement Therapies 24 (2020) 568e574
between the two techniques
when using the perineometer.
Comparison between groups
when evaluating the PFM
strength was not conducted
Hung et al. SIB CG M 33 EG M 31 18 to 65 MVC perineometry - Abdominal exercises þ PFMT 2/months No identified 12 8 The addition of abdominal
(2010) 18 to 65 12 exercises did not increased PFM
strength

- PFMT

Culligan et al. Healthy CG M 30 EG M 32 51.1 ± 10.648.8 ± 12.1 MVC perineometry -Pilates 2/week 60 12 6 The two groups increased the
(2010) 2/week 60 12 PFM strength

- PFMT
Resende et al. POPC CG M 21 EG 1M 56.7 ± 10.7 MVC palpation - Hypopressive þ PFMT 1 60 12 8 The two groups increased PFM
(2012) 21 EG.2M 16 51.9 ± 7.4 endurance strength
58.7 ± 10.4 electromyography - PFMT with defined protocol. 1 60 12 The addition of hypopressive
exercise did not increase PFM
strength
- PFTM without defined protocol. 1 60 12
Torelli et al., Sedentary CG M 24 EG M 24 27.41 ± 4.8 MVC palpation -Pilates 2/months 60 16 8 The PFTM þ Pilates increased
2016 27.98 ± 5.4 perineometry PFM strength compared to
Pilates
- Pilates þ PFMT 2/months 60 16
Gomes et al. PPUID CG H 34 EG.1H 66.62; 5.66 MVC palpation -Pilates 10/weeks 45 10 8 There was a significant
2017 35 EG.2H 35 (65.83):5.6463.11. perineometry difference before and after in
endurance the PFMT þ PE group
-PFMT þ PE 10/weeks 45 10 There was no difference
between groups in PFM
strength
- PFMT 0 0 10
Resende et al. POPC CG M 31 EG M 30 55 ± 6.2 MVC palpation -Hypopressive 2/months No identified 12 8 The two groups increase PFM
(2019) 56.5 ± 4.3 electromyography strength
-PFMT 2/months 12 PFMT is superior to
Hypopressive

571
572 R.H. Jacomo et al. / Journal of Bodywork & Movement Therapies 24 (2020) 568e574
Fig. 2. Risk of Bias graph: judgments by the reviewer about each item of risk of bias in
the included studies, presented as a percentage.
Caufriez, 1997). However, greater activation does not translate into
pelvic floor muscle strength gain (Luginbuehl et al., 2015). The in-
fluence of these exercise regimens on PFM strength is controversial.
As described in a previous review and confirmed by this review,
Pilates performed alone does not significantly improve PFM strength
(Lemos et al., 2019). The difference between the Lemos et al. study
and our study is that Lemos et al. did not compare Pilates with
electrical stimulation or any other type of PFMT. Only Culligan et al.,
2010, observed an increase in PFM strength.
Two studies compared three types of treatment (Resende et al.,
2012; Gomes et al., 2018). Gomes et al. (2018), randomized patients
into three groups: the Pilates (1), PFMT with electrical stimulation
(2), and PFMT groups (3). Moreover, Resende et al. (2012), divided
patients into the hypopressive with PFMT (1), PFMT with a defined
protocol (2), and PFMT without a defined protocol groups (3). It is
noteworthy that in both studies, the results for PFMT without a
Fig. 3. Bias Risk Summary: judgments by the reviewer about each item of risk of bias
in the included studies.
defined protocol were unsatisfactory. It has been shown that 30% of
women are unable to contract their PFMs correctly (Hilde and
Staer-Jensen, 2014). This result highlights the importance of well-
monitored PFMT. A Brazilian study that was conducted with 72
women showed that unsupervised PFMT without a defined pro-
tocol is complex and that directions should always be given
(Sacomori et al., 2018).
In this review, we found that the Paula method is a technique
used to improve PFM strength. The Paula method is based on the
theory that the sphincters of the body work together and may affect
one another. According to this theory, weakness of the levator ani
can be improved by exercising circular muscles, such as those in the
eye, nose and mouth (Yom-Tov and Golani, 1993). Liebergall-
Wischnitzer et al., 2005, conducted a study to determine the
effectiveness of the Paula method compared with PFMT in the
management of UI. Subjects participated in a RCT comparing 2
exercise programs, one involving 12 sessions of the Paula method
and the other involving 6 PFMT classes. The authors observed an
increase in PFM strength in both groups. However, PFM strength
was not compared between the two groups. Resende et al.
measured PFM strength using the Paula method and concluded
that the Paula method was unable to increase PFM electrical ac-
tivity 33. This article was excluded from our review because it had a
cross-sectional design.
Two studies measured the efficacy of including hypopressive
exercises in pelvic floor muscle training programs (Resende et al.,
2012, 2019). Both studies included a study population of women
who had suffered from pelvic organ prolapse for over three months.
Resende et al. (2019), concluded that PFMT was superior to hypo-
pressive exercises for all outcomes measured. Resende et al. (2012),
showed that including hypopressive exercises in PFMT programs
does not improve PFM function.
Only one study examined the effects of functional abdominal
exercises. Hung et al. investigated the effects of treating the dia-
phragm and deep abdominal muscles and using PFMT in women
suffering from UI for eight individual clinical visits (Hung et al.,
2010). The amount of leakage and the number of leaks were
significantly lower when both PFMT and abdominal training were
performed than when PFMT only was performed (p < 0.05). How-
ever, the authors observed improvements in PFM strength in both
groups. However, the study failed to compare PFM strength be-
tween the groups, hampering the analysis.
The majority of the studies used palpation to assess the PFMs
(Liebergall- Wishchnitzer et al., 2005; Resende et al., 2012; Torelli
et al., 2016; Gomes et al., 2018; Resende et al., 2019). According to
the ICS recommendations, PFM contractions are classified as ab-
sent, weak, normal, or strong (Bo et al., 2016). Several methods are
used to evaluate PFM function, including palpation, ultrasonogra-
phy, magnetic resonance imaging, perineometry and electromy-
ography (Frawley et al., 2006). Multiple tools and scales, such as
bidigital palpation, electromyography, perineometry and dyna-
mometry, are used to evaluate PFM contractions, but vaginal
palpation is considered the gold standard (Fitz et al., 2012; Mateus-
Vasconcelos et al., 2018). The studies used the subjective Oxford
scale due to its high reliability (Laycock and Jewood, 1994). Several
studies have assessed the association of palpation with other types
of assessment, such as electromyography and perineometry, but no
associations have been identified (Isherwood and Rane, 2000). The
rationale is that each instrument evaluates different muscle prop-
erties. While dynamometers evaluate strength, palpation evaluates
function, and electromyography evaluates the electrical activity of
the muscle (Laycock and Jerwood, 1994).
The strengths of the present study are that the benefits of
applying other methods, such as nonspecific exercise methods, for
treating and preventing pelvic floor dysfunctions were revealed.
 R.H. Jacomo et al. / Journal of Bodywork & Movement Therapies 24 (2020) 568e574
One possible limitation is that the number of articles identified was
small. However, despite the small number of articles, the articles
chosen allowed the identification of significant associations. It is
also important to highlight that the techniques presented in this
systematic review are widely used, despite there being a lack of
scientific evidence of their efficacy.
It is important to note that few papers have discussed the
impact of alternative exercise regimens on PFM strength,
hampering a complete analysis or meta-analysis. However, the
studies had good methodological quality scores, according to the
PEDro scale.
5. Conclusion
Considering the studies available, alternative exercises such as
Pilates, the Paula method and hypopressive exercises are ineffective
in strengthening the pelvic floor musculature. Pelvic floor muscle
training continues to be the gold standard technique for increasing
pelvic muscle strength.
Funding
None.
PROSPERO registration number
CRD42019123396.
Publication status
Paper must not have been published before.
CRediT authorship contribution statement
Raquel Henriques Jacomo: Substantial contributions to
conception and design. Tatiana Reis Nascimento: Substantial
contributions to conception and design. Marianne Lucena da Siva:
Writing - original draft. Mariana Cecchi Salata: Writing - original
n
draft. Aline Teixeira Alves: Writing - original draft. Pedro Rinco
~o
Cintra da Cruz: Final approval of the version to be published. Joa
Batista de Sousa: Revision and final approval of the version to be
published.
Declaration of competing interest
None.
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