Erika Alejandra Pulido Briseño*

erika.pulido@anahuac.mx

Paola Teresa Penagos Gómez**

paola.penagos@anahuac.mx

Jimena Figueroa Valero+

jimena.figueroa@anahuac.mx

Estrella Jalife Galante++

estrella.jalifega@anahuac.mx

*Egresada de la Licenciatura en Terapia Física y Rehabilitación

de la Universidad Anáhuac Norte

Coach certificada de ejercicios hipopresivos en Low Pressure Fitness

**Docente Licenciatura en Terapia Física y Rehabilitación

de la Universidad Anáhuac Norte

Fisioterapeuta, Doctoranda en Bioética aplicada

Mg. en Desarrollo infantil

Mg. en Actividad física, gestión y entrenamiento deportivo

Especialista en Docencia para la educación superior

Vinculada al grupo de investigación

Capacidades humanas, salud e inclusión de la ECR

Investigadora asociada de la Universidad Anáhuac Norte

Instructora en simulación clínica

+Coordinadora de la Licenciatura en Terapia Física y Rehabilitación

de la Universidad Anáhuac

Licenciada en Terapia Física y Rehabilitación

Maestra en Ciencias Médicas y Doctoranda en Bioética Aplicada

Docente titular de Fundamentos en Terapia física, Bases de biomecánica

y rehabilitación musculoesquelética

Presidenta de la Dirección Académica de la Federación Mexicana

de Fisioterapia, terapia física y Kinesiología

Instructora en simulación clínica

++Docente de la Licenciatura en Terapia Física y Rehabilitación

de la Universidad Anáhuac Norte

Licenciada en Terapia Física y Rehabilitación

Escuela de Medicina Física y Rehabilitación Adele Ann Iglesias

Fisioterapeuta especializada en rehabilitación de suelo pélvico

Especialista en fisioterapia aplicada a sexología

Master Coach certificada de ejercicios hipopresivos en Low Pressure Fitness

(México)

Reception: 04/12/2024 - Acceptance: 05/12/2024

1st Review: 05/08/2024 - 2nd Review: 05/12/2024

Accessible document. Law N° 26.653. WCAG 2.0

Suggested reference: Pulido Briseño, E.A., Penagos Gómez, P.T., Figueroa Valero, J., y Jalife Galante, E. (2024). Hypopressive Exercise for the Treatment of Adults with Chronic Nonspecific Low Back Pain. Narrative Review. Lecturas: Educación Física y Deportes, 29(315), 155-174. https://doi.org/10.46642/efd.v29i315.7555

 

Abstract

    Chronic non-specific low back (NSCLBP) pain significantly affects the population, being the main cause of disability, work absenteeism, early retirement, and a serious public health problem that affects the quality of life of the adult population and its economy. Physiotherapy presents itself as an alternative for the management of chronic low back pain (CLBP), through different modalities and specific exercises aimed at proper functioning of the trunk muscles. Within this area are hypopressive exercises (HE). The aim of this article is to determine the effectiveness of HE in the treatment of NSCLBP adults, conducting an exploratory and descriptive bibliographic study that compiled evidence from bibliographic sources PubMed, Scielo, Ebsco, Dialnet, Elsevier, Science Direct, PEDro, and SAGE Journals, with quartile between Q1 and Q4, in an observation window between 2018 and 2024, with no age, gender, and language restriction. The results yielded 5 articles which met the eligibility criteria. It was possible to recognize that 4 of these articles affirm a significant decrease in the Numerical Rating Scale that was used to measure low back pain after an intervention of HE. In conclusion, according to these studies, HE represents a non-invasive alternative to address NSCLB and have significant effects to reduce pain and improve functionality in people who suffer from these symptoms that are currently affecting the adult population.

    Keywords: Low back pain. Exercise therapy. Literature review.

 

Resumen

    El dolor crónico inespecífico de espalda baja afecta significativamente a la población, siendo la principal causa de discapacidad, ausentismo laboral, jubilación anticipada y es un grave problema de salud pública que repercute en la calidad de vida de la población adulta y en su economía. La fisioterapia se presenta como una alternativa para el manejo del dolor lumbar crónico, a través de diferentes modalidades y ejercicios específicos dirigidos a un correcto funcionamiento de los músculos del tronco. Dentro de este ámbito se encuentran los ejercicios hipopresivos. El objetivo de este artículo es determinar la eficacia de los ejercicios hipopresivos en el tratamiento del dolor lumbar crónico inespecífico en adultos, llevando a cabo un estudio bibliográfico exploratorio y descriptivo que recopiló evidencia de las fuentes bibliográficas PubMed, Scielo, Ebsco, Dialnet, Elsevier, Science Direct, PEDro, and SAGE Journals, con quartil entre Q1 y Q4, en una ventana de observación entre 2018 y 2024, sin restricción de edad, género e idioma. Los resultaron arrojaron 5 artículos, los cuales cumplían con los criterios de elegibilidad, en los cuales se pudo reconocer que 4 de estos artículos afirman una disminución significativa en la Numerical Rating Scale (NRS) que fue utilizada para medir el dolor lumbar después de una intervención de ejercicios hipopresivos. En conclusión, según estos estudios, los ejercicios hipopresivos representan una alternativa no invasiva para poder abordar el dolor lumbar crónico inespecífico y tienen efectos significativos para reducir el dolor y mejorar la funcionalidad, síntomas que están afectando actualmente a la población adulta.

    Palabras clave: Dolor lumbar. Terapia por ejercicio. Revisión de literatura.

 

Resumo

    A dor lombar crônica inespecífica afeta significativamente a população, sendo a principal causa de incapacidade, absenteísmo no trabalho, aposentadoria precoce e um grave problema de saúde pública que afeta a qualidade de vida da população adulta e sua economia. A fisioterapia se apresenta como uma alternativa para o manejo da dor lombar crônica, por meio de diferentes modalidades e exercícios específicos que visam o bom funcionamento da musculatura do tronco. Dentro desta área estão os exercícios hipopressivos. O objetivo deste artigo é determinar a eficácia dos exercícios hipopressivos no tratamento da dor lombar crônica inespecífica em adultos, realizando um estudo bibliográfico exploratório e descritivo que compilou evidências das fontes bibliográficas PubMed, Scielo, Ebsco, Dialnet, Elsevier, Revistas Science Direct, PEDro e SAGE, com quartil entre Q1 e Q4, em uma janela de observação entre 2018 e 2024, sem restrição de idade, sexo e idioma. Os resultados renderam 5 artigos que atenderam aos critérios de elegibilidade. Foi possível reconhecer que 4 desses artigos afirmam uma diminuição significativa na Escala Numérica de Avaliação que foi utilizada para medir a dor lombar após uma intervenção de exercícios hipopressivos. Concluindo, de acordo com esses estudos, os exercícios hipopressivos representam uma alternativa não invasiva para tratar a dor lombar crônica inespecífica e têm efeitos significativos na redução da dor e na melhoria da funcionalidade em pessoas que sofrem desses sintomas que atualmente afetam a população adulta.

    Palavras-chave: Dor lombar. Terapia por exercício. Revisão de literatura.

 

Lecturas: Educación Física y Deportes, Vol. 29, Núm. 315, Ago. (2024)

---

 

Introduction 

 

    Chronic low back (CLBP) it is a symptom of pain that extends from the last rib to the gluteal fold. It can be localized pain or referred pain radiating to the lower limbs and it is considered chronic when more than 12 weeks have passed and the pain persists, or if the same pain occurs repeatedly for 6 Months (Barrey, & Le Huec, 2019; Dada Santos et al., 2021) . For the past 30 years, chronic low back pain has been the leading cause of disability globally and a significant public health issue, resulting in high direct costs for medical care and productivity, although the prevalence rates of people seeking medical care vary internationally (Li et al., 2023). It is believed that at least 70% to 85% of people experience low back pain during their lives (Hajihasani et al., 2019). In Mexico, besides being the main cause of disability, it also represents the primary reason for work absenteeism and early retirement (Alva Staufert et al., 2021) . This turns it into a serious public health issue affecting the population aged 20 and above, with frequencies ranging from 15% to 36%, as well as its economy. (Alva Staufert et al., 2021; Soto et al., 2015)

 

    This pain affects the quality of life by limiting cognitive functions, restricting social, work, and recreational activities, as well as the emotional well-being, contributing to increased anxiety, sleep disorders, depression and represents a higher cost for public health services. (Alemanno et al., 2019; Hajihasani et al., 2019)

 

    The traditional management used to control the symptoms of NSCLB has mainly involved the use of medications such as opioids and NSAIDs (nonsteroidal anti-inflammatory drugs), sometimes combined with acetaminophen. Although their efficacy in treating CLBP has been demonstrated, their use for more than 4 weeks it is not recommended due to the potential for side effects, especially with opioids, which may outweigh their benefits and lead to drug dependence (Alleva et al., 2016; Jiménez-Ávila et al., 2019) . This treatment is supported by the following clinical guideline (Kreiner et al., 2020). Another type of medication that can be used is gabapentinoids and pregabalin, which belong to the newer generation of anticonvulsants. However, although they have a low risk of dependence and have shown efficacy for this symptomatology there is not enough solid evidence regarding their misuse. (Vasudeva & Tripathi, 2023)

 

    If medication is not sufficient to control the pain, surgery is considered. But it is important to inform the patient about postoperative care, as it can be painful, with intensities ranging from moderate to severe, especially during the first 48 hours (De Lara González et al., 2019). There are also complications related to lumbar spine surgery, such as residual neuropathy, dural tears, and surgical wound infections (Daneri-Allis et al., 2021). And there is a probability ranging from 5% to 74.6% of experiencing "Failed Back Syndrome" or "Failed Back Surgery Syndrome", which is back pain that persists despite undergoing lumbar spine surgery. This issue affects between 10% and 40% of patients after undergoing back surgery. Failure rates vary, ranging between 30% and 46% for lumbar fusion, and between 19% and 25% for microdiscectomy (Orhurhu et al., 2024). The proposed treatment for this syndrome is conservative, involving physiotherapy, medication or even result in another surgery (Orhurhu et al., 2024; Ramirez et al., 2017). Recent studies have confirmed the effectiveness of exercise as an intervention method for individuals suffering from CLBP in reducing pain and improving bodily function. Techniques such as tai chi, yoga, resistance training, and exercises focused on trunk stabilizing muscles are more effective than other types of interventions (Li et al., 2023; Syroyid Syroyid et al., 2023). This is the focus of physiotherapy treatment, where therapeutic exercises and other modalities have reduced pain by 20 to 30% in patients (Hansford et al., 2023; Will et al., 2018). Additionally, improvements in functionality and a lower risk of pain recurrence have been observed (Santamaría et al., 2023). Contrary to previous beliefs that patient rest reduced pain, there is a relationship between physical activity and aerobic capacity, which is targeted in physiotherapy treatment resulting in decreased pain, disability reduction, and improved mobility in patients with CLBP. (Alarab et al., 2023)

 

    CLBP can have multiple triggers, among which are risk factors such as lack of strength in the muscles, both superficial and deep in the trunk, and abdominal muscles (Sipaviciene, e Kliziene, 2020). As part of the physiotherapy treatment for CLBP, HE created in the 1980s, have begun to be used as a method of pelvic floor rehabilitation in postpartum (Alonso Calvete et al., 2019) . These are postural and respiratory exercises that promote proper management of pressures in the abdominal, thoracic, and pelvic cavities. Additionally, they have emerged as a therapeutic exercise option utilized by physiotherapist for the management of lower back pain. They promote correct activation and increased tone in the trunk muscles, including the stabilizing muscles of the spine (Flores López, e Uclés Villalobos, s. f.; Hernández Rovira et al., 2024; Vicente-Campos et al., 2021). It has been found that these exercises yield benefits in improving postural activation, mobility, deep trunk muscles, and respiratory function, as well as in regulating the sympathetic nervous system. Moreover, they are effective treatments for reducing abdominal measurements and closing abdominal diastasis. However, there are still some variables that have not been widely studied. (Hernández Rovira et al., 2024; Meurer et al., 2023; Molina‐Torres et al., 2023)

 

    However, despite the previously mentioned benefits, it is necessary to conduct research to identify how this type of exercise can be applied based on available scientific evidence, and how it can be implemented in clinical settings. This research is essential and relevant to address the need for understanding the practical application of these exercises and their potential benefits in the treatment of CLBP in adults. The deficiency in the literature on this topic justifies the need to conduct a review on hypopressive exercises for low back pain. Based on the above, this exploratory and descriptive bibliographic research is proposed, aimed at analyzing and discussing the available evidence on the effectiveness of HE for the treatment of NSCLBP in adults. It is expected that the results obtained will provide highly cost-effective therapeutic options that contribute to improving the clinical outcomes and quality of life of populations affected by this health condition.

 

Methods 

 

    The present study corresponds to a narrative and descriptive bibliographic research, through which the collected information from various bibliographic sources is described, synthesized, and discussed.

 

Search strategy 

 

    A review was conducted on databases including PubMed, Scielo, Ebsco, Dialnet, Elsevier, Science Direct, PEDro, and SAGE Journals. Using the PICO structure, the aim was to structure and focus the clinical research question by delineating the population of interest, the intervention, the comparison, and the anticipated research outcomes A review was conducted on databases including PubMed, Scielo, Ebsco, Dialnet, Elsevier, Science Direct, PEDro, and SAGE Journals. Keywords were extracted, thus forming various combinations in English with the respective use of Boolean operators as follows: ((MH "Abdominal Exercises") AND "hypopressive" AND ((“Chronic Low Back Pain) OR (“Non-specific Low Back Pain”))) OR ((MH "Abdominal Muscles") AND "hypopressive" AND (("Chronic Low Back Pain") OR ("Non-specific Low Back Pain")))

 

Selection criteria 

 

    Considered for inclusion were various study types, including clinical trials, controlled trials, case reviews, prospective studies, retrospective studies, and quasi-experimental studies. The Scimago Journal & Country Rank, with quartiles ranging from Q1 to Q4, serves as a tool for evaluating scientific production, aiming to measure the impact of publications. Categorizing journals into quartiles, where Q1 represents journals with the highest impact and Q4 represents those with the lowest impact (Souza et al., 2019). In an observation window between 2018 and 2024, with no age, gender, and language restriction.

 

Procedures 

 

    All articles were collected from the previously mentioned sources, resulting in 43 articles. The studies whose titles did not match the search and duplicates were manually removed, they were then selected first through an abstract selection process aimed at discarding ineligible studies, and then the remaining studies were evaluated and read in full to verify that the inclusion and exclusion criteria were met, resulting in a total of 5 articles related to HE and CLBP displayed in Figure 1.

 

Figure 1. Study algorithm

Source: Survey data (2024)

 

Results 

 

Study descriptions 

 

    Of the analyzed studies, 5 met the established eligibility criteria. Regarding the number of publications per year, the following was found: 1 study was published in 2018, 2 studies were published in 2021, 1 in 2022, and finally 1 study in 2023. Regarding the typology of the research, the findings were as follows: 1 randomized controlled trial, 1 randomized controlled pilot study, 1 single-blinded randomized controlled trial, 1 clinical trial, and the last one was a before-and-after intervention study. In terms of language, all are in English, and regarding the country, 4 out of 5 studies were conducted in Spain, except for 1 conducted in Brazil (Table 1).

 

Title	Clinical relevance of massage therapy and abdominal hypopressive gymnastics on chronic nonspecific low back pain: a randomized controlled. (Bellido-Fernández et al., 2022)	Effectiveness of Massage Therapy and Abdominal Hypopressive Gymnastics in Nonspecific Chronic Low Back Pain: A Randomized Controlled Pilot Study.  (Bellido-Fernández et al., 2018)	The Main Role of Diaphragm Muscle as a Mechanism of Hypopressive Abdominal Gymnastics to Improve Non-Specific Chronic Low Back Pain: A Randomized Controlled Trial.  (Vicente-Campos et al., 2021)	Effects of Hypopressive Exercise on Posterior Back Chain Kinematics and Pulmonary Function in Professional Female Basketball Players.  (Teijido et al., 2022)	Can 5-weeks of Hypopressive Exercise Influence Sagittal Lumbo Pelvic Position in Athletic and Non-Athletic Females?  (Wojcik et al., 2023)
Objective	Determine the relevance of the effects of manual therapy, hypotensive exercises, and the combination of both interventions on disability, pain intensity, and lumbar mobility in patients with chronic nonspecific low back pain.	Determine whether manual therapy and HE or the combination of both have effects on quality of life and health in patients with nonspecific low back pain.	Determine the effects of an 8-week hypopressive exercise intervention on inspiratory muscle strength, diaphragm thickness, disability, and pain intensity in patients with chronic nonspecific low back pain.	Examine the effects of a hypopressive exercise intervention on posterior back chain kinematics, thoracic mobility, pulmonary function, and lower lumbar pain in female basketball players.	Evaluate whether a hypopressive exercise intervention influences lumbopelvic sagittal positioning in female athletes compared to non-athletic athletes.
Author	Bellido-Fernández, L., Jiménez-Rejano, J.J., Chillón-Martínez, R., Lorenzo-Muñoz, A., Pinero-Pinto, E., Rebollo-Salas, M.	Bellido-Fernández, L., Jiménez-Rejano, J.J., Chillón-Martínez, R., Gómez-Benítez, M.A., De-La-Casa-Almeida, M., Rebollo-Salas, M.	Vicente-Campos, D., Sánchez-Jorge, S., Terrón-Manrique, P., Guisard, M., Collin, M., Castaño, B., et al.	Teijido, S.L., Rial Rebullido, T., Gómez-Tomás, C., Alonso-Aubin, D.A., Chulvi-Medrano, I.	Wojcik, K., Machado, L., Bastos de Brito, C., Rial Rebullido, T.
Year	2021	2018	2021	2022	2023
Language	English	English	English	English	English
Country	Spain	Spain	Spain	Spain	Brazil
Type of study	Randomized controlled trail	Randomized Controlled Pilot Study	Single-blinded, randomized controlled trial (blinded examiner)	Clinical trial with pre-, mid-, and post- intervention assessments	Before and after intervention study

Source: Authors' own data 2024

 

Summary of included studies 

 

    In the final review, the mentioned 5 articles were included. Of these, 4 out of the 5 articles reported a significant decrease in the Numerical Rating Scale (NRS) used to measure NSCLBP after a hypopressive exercise intervention. The first article reported a p-value of less than 0.05, the second article reported p=0.499, the third article p=0.001, and the fourth article p=0.003. The remaining article used the VAS scale and did not report a significant decrease, with a p-value of 0.88; however, low back pain was reported by 35% of the participants, and although there was a trend towards a decrease in low back pain, it was not significant.

 

    Additionally, significant improvements were observed in 3 out of the 5 articles where scales were used to measure disability index such as Oswestry and Roland Morris. An increase in lumbar mobility was observed in 3 articles, where the Schober scale or finger to floor test was used. Moreover, significant differences were reported in the SF-12 questionnaire, which measures patient quality of life, in 2 articles.

Furthermore, HE were shown to be effective in reducing abdominal circumference, improving thoracic mobility, forced expiratory volume, and other spirometry measures, and they were also associated with an increase in diaphragm thickness. These findings suggest that HE may be an effective intervention for controlling CLBP (Table 2).

 

Author	Bellido-Fernández, L., Jiménez-Rejano, J.J., Chillón-Martínez, R., Lorenzo-Muñoz, A., Pinero-Pinto, E., Rebollo-Salas, M.	Bellido-Fernández, L., Jiménez-Rejano, J.J., Chillón-Martínez, R., Gómez-Benítez, M.A., De-La-Casa-Almeida, M., Rebollo-Salas, M.	Vicente-Campos, D., Sánchez-Jorge, S., Terrón-Manrique, P., Guisard, M., Collin, M., Castaño, B., et al.	Teijido, S.L., Rial Rebullido, T., Gómez-Tomás, C., Alonso-Aubin, D.A., Chulvi-Medrano, I.	Wojcik. K., Machado, L., Bastos de Brito, C., Rial Rebullido, T.
Participants	60 adults with chronic nonspecific low back pain with mechanical pain for at least 12 weeks and had no severe complications. Range of age: 20 to 65 years Gender: 45 females and 15 males.	27 adults with chronic nonspecific low back pain with mechanical pain for at least 12 weeks and had no severe complications. Range of age: 20 to 65 years Gender: 23 females and 4 males.	40 adults with a diagnosis of chronic low back pain of non-specific origin carried out by a medical doctor. Range of age: Gender: 24 females and 16 males.	17 females adults professional basketball players with symptoms of nonspecific lower back pain.	20 females adults with symptoms of nonspecific lower back pain Age range between 18 to 31 years.
Control group	No control group	No control group	20 adults with 9 males and 11 females	No control group	10 females adults
Intervention group	Massage Therapy (20), group 2 Abdominal hypopressive gymnastics (20) and group 3 Massage Therapy + hypopressive gymnastics (20)	Massage Therapy (9), group 2 Abdominal hypopressive gymnastics (9) and group 3 Massage Therapy + hypopressive gymnastics (9)	20 adults with 7 males and 13 females	17 professional females basketball players	10 females adults
Prescription	5 weeks that included 8 interventions, 30 minutes per intervention. The first 3 weeks 2 interventions per week and the last 2 weeks 1 intervention per week. Group 1: 8 manual therapy interventions Group 2: 8 hypopressive interventions Group 3: 4 hypopressive interventions and 4 manual therapy.	5 weeks that included 8 interventions, 30 minutes per intervention. The first 3 weeks 2 interventions per week and the last 2 weeks 1 intervention per week. Group 1: 8 manual therapy interventions Group 2: 8 hypopressive interventions Group 3: 4 hypopressive interventions and 4 manual therapy.	8 weeks in which the experimental group had hypopressive exercise interventions 2 times a week, with a duration of 30 to 40 minutes per intervention and the control group was asked to continue with their usual physical activity routines.	8 weeks of intervention with one session of HE per week before his basketball training, ending with 3 to 4 minutes of normal breathing.	5 weeks of hypopressive exercise intervention, 2 times a week 20-minute sessions.
Variables analyzed	Disability, pain intensity, quality of life, lumbar mobility, gender, age.	Gender, age, Disability index, pain intensity, lumbar mobility, quality of life.	Diaphragm Thickness, inspiratory muscle strength, pain intensity, pain threshold, physical activity levels, disability, central sensibilization, kinesiophobia.	Age (years), body height (centimeters), body weight (kilograms), body mass index (kg/m^2), years of sports practice (years), frequency of basketball training (days/week), low back pain.	Age – years, anthropometric measurement, body mass – kg, body height – cm, body mass, index - kg/cm², lumbar sagittal position (LL) (degrees), pelvic horizontal alignment Angle (PHA) (degrees), abdominal circumference at three different anatomical locations: midway circumference (MC) (cm), umbilical circumference (UC) (cm), infraumbilical circumference (IC) (cm), body Weight (kg), low Back Pain Intensity (LBP).
Instruments	Disability – Oswestry, Disability Index (ODI), Pain intensity - Numerical Rating Scale (NRS) that ranges from 0 1⁄4 no pain to 10 1⁄4 maximum pain, Quality of life- SF-12, Lumbar mobility – Schober.	Pain intensity- Numerical Rating Scale (NRS), disability- Oswetry Disability Index, quality of life-Sf-12 questionnarie, lumbar flexibility- Schober Test.	Diaphragm Thickness- ultrasonography with the Toshiba Xario 100 device, inspiratory Muscle Strength Assessed –POWER breathe KH1 device measuring maximum inspiratory pressure (PImax), pain Intensity- Numerical Rating Scale (NRS), pain Threshold- digital algometer on the spinous process of the L4 lumbar vertebra, international Physical Activity Questionnaire (IPAQ), Roland–Morris-Disability Questionnaire (RMDQ), central Sensitization Inventory (CSI).  Tampa Scale of Kinesiophobia-11 Items (TSK-11).	Posterior back chain kinematics Finger to floor test- lumbosacral and hip joint (hamstring) flexibility. Sit and reach test - back chain flexibility excluding balancing demands. Spirometry: - Forced Vital Capacity (FVC) - Peak Expiratory Flow (PEF) - Forced Expiratory Volume (FEV) - FEV between 25% and 75% (FEV25–75) - Ratio between FEV in the first second and Forced Vital Capacity (FEV1/FVC) Thoracic mobility- chest wall expansion at the level of T10 using a tape measure, numerical rating scale.  (NRS) -pain levels.	Visual Analog Scale (VAS) - Low back pain intensity Two dimensional photogrammery- to assess sagittal lumbo-pelvic position. Nikon D500 18–55 mm digital camera used to capture photographs in a right lateral view. Double-sided tape and polystyrene spheres (1 cm diameter) used to fix on the posterior-inferior iliac spines and anterior-superior iliac spines of participants. Balmak EST-221 Sanny professional stadiometer used to measure height ActLife model scale from Balmak used to determine weight. WISO flexible non-elastic anthropometric tape used to measure abdominal circumference at three different anatomical sites (MC, UC, IC) Postural Evaluation (SAPO) software used to analyze photographs captured during photogrammetry.
Results	The Oswetry scale scores were significantly higher (p<0.5) in the manual therapy + abdominal gymnastics group. Significant differences were found in the numerical rating scale to measure pain, Schober's test for lumbar mobility and SF-12 to measure quality of life in each group (p<0.05) Significant differences in (p < 0.05) between the values of SF-12 MCS in hypopressive abdominal gymnastics and manual therapy + hypopressive abdominal gymnastics groups.	Both individual groups reduce pain levels (p= 0,499), improve disability (p=0,025), and increase the flexibility of the lumbar spine (p=0,256).	Significant differences (p <0.025) in diaphragm thickness, higher PImax and lower scores in the NRS scale that evaluates pain, which means significant reduction of pain in the patient, as well as lower scores in CSI and RMQ in the intervention group compared to the control group.	The analysis of variance revealed significant differences between the 3 measurement periods for thoracic mobility (P >.01); forced expiratory volume in the first second (P <.05). Significant differences between baseline and after the intervention for the sit and reach test (P >.01), peak expiratory flow (P =.01), and forced expiratory volume in the first 25 seconds (P =.04). Also, significant differences between weeks were found in levels of lumbar pain (P =.003) and the finger to floor test (P =.002).	Abdominal circumference significantly decreased at all anatomical locations after the intervention in both groups, p= (0.005,0.008, 0.017/ 0.018, 0.005, 0.017) Significant correlations were found between abdominal circumference measurements at different anatomical sites, both before and after the intervention. Although low back pain was reported by 35% of participants, there were no significant reductions between measurement moments or differences between groups. - Comparison between athletic vs non-athletic group (p= 0.88) - Comparison between moments for all (p= Sedentary group 0.109.

Source: Authors' own data

 

Participants 

 

    The participants in the studies included in this narrative and descriptive bibliographic research totaled 147 adults, comprising 120 women and 27 men. The age range provided in the studies was from 18 to 65 years old. However, in two out of the five studies, the age range was not specified. All participants were diagnosed with NSCLBP and had no severe complications. The first study involved 60 adults, whose ages ranged from 20 to 65 years old, with a gender distribution of 45 women and 15 men. The second study, comprising 27 adults in the same age range, had a ratio of 23 women to 4 men. In the third study, which included 40 adults, no information was provided regarding the age range, but there was a ratio of 24 women to 16 men. In the fourth study, 17 adult women, basketball players, participated without specifying their age range, while the fifth study involved 20 women aged between 18 and 31 years old.

 

Prescription 

 

    The treatment prescription in the reviewed studies encompasses different modalities and durations. In the first and second articles, each lasting 5 weeks, 8 sessions of 30 minutes were administered, including a manual therapy protocol. These two studies were divided into three groups: one with exclusive manual therapy, another with HE, and a third with a combination of both modalities. The third article spanned 8 weeks, conducting a total of 16 sessions of HE lasting 30 to 40 minutes each. The fourth article, also lasting 8 weeks, consisted of 8 sessions, without detail on the duration of each. Finally, in the fifth article, lasting 5 weeks, 10 sessions of 20 minutes each were conducted. These variations in duration and treatment modalities provide a diverse insight into the interventions applied in the management of CLBP.

 

Instruments 

 

    The instruments used in the five studies were selected to measure the pain experienced by the participants. In the first, second, and third articles, the Numeric Rating Scale (NRS) was employed for this measurement. Available in two versions, NRS-11 and NRS-101, it is designed to measure pain on scales of 11 or 101 points respectively. Widely employed in clinical settings, due to its ease of administration and scoring (Bielewicz et al., 2022). Additionally, in the third study, a digital algometer was used on the spinous process of the L4 lumbar vertebra to measure pain threshold. On the other hand, in the fourth article, the Numeric Rating Scale (NRS) was again utilized. Finally, in the fifth study, the Visual Analog Scale (VAS) was chosen to assess pain, this is a visual scale in which the patient is asked to visualize and represent the pain they are experiencing as a point on a 10 cm line presented on paper (Bielewicz et al., 2022). These instruments provided a quantitative tool for evaluating the intensity of pain in each of the studies.

 

Discussion 

 

    This study aimed to determine the effectiveness of HE in treating NSCLB. The results revealed that in 4 out of the 5 articles analyzed, HE were found to be effective in reducing and treating NSCLBP, with the method used to measure these outcomes being the NRS scale.

For the past 30 years, chronic low back pain has been the leading cause of disability globally and a significant public health issue, resulting in high direct costs for medical care and productivity loss (Li et al., 2023). This symptom not only impacts the quality of life of the population but also affects cognitive function and emotional well-being, leading to anxiety, sleep problems, decreased quality of life, increased disability, and depression. (Alemanno et al., 2019; Hajihasani et al., 2019)

 

    However, there are non-invasive alternatives that can address, reduce, and prevent this public health problem. According to the literature, a physiotherapy program has shown a decrease in pain in patients with NSCLBP ranging from 20 to 30% (Hansford et al., 2023) , while also reducing the risk of recurrence of this symptom (Santamaría et al., 2023) .The practice of specific exercises to strengthen the core improves mobility and strength of the pelvic muscles, which are related to lessening CLBP. HE have emerged as a particularly effective option to properly activate the core muscles. (Kim & Yim, 2020)

 

    Several studies (Bellido-Fernández et al., 2018, 2022; Teijido et al., 2022; Vicente-Campos et al., 2021) have demonstrated the effectiveness of HE protocols in reducing pain. It is important to highlight that the majority of the articles implemented intervention lasting 5 to 8 weeks, with at least 2 weekly sessions of HE, each lasting at least 30 minutes. This suggests that longer duration and frequency of sessions may allow for greater exposure to HE, potentially leading to an improvement in NSCLBP symptoms. These articles have also documented other health benefits, such as improved postural activation, mobility, deep trunk muscles, respiratory function, as well as regulating the sympathetic nervous system. Moreover, HE are effective treatments for reducing abdominal measurements and closing abdominal diastasis. However, it is also important to note the variability in results, as evidenced by a study by Wojcik et al. (2023) where no significant reduction in pain was found following a 5-week HE intervention in patients with NSCLBP.

 

    Despite the effects that HE have in reducing NSCLBP, it is essential to recognize potential factors that may influence the interpretation of the results. One important point is the predominance of female participants in studies on HE. This could make a difference according to gender in these types of interventions, which could change the results if the population is diverse. Additionally, the limited geographic scope, as 4 studies were conducted in the same country, may impact the generalization of the results to other populations. A significant limitation could be the relatively low number of articles included in this review, highlights the paucity of experimental or quasi-experimental studies in this field. This scarcity could be attributed to the fact that hypopressive exercises are relatively recent in the research field and the ongoing process of consolidating scientific evidence.

 

    Therefore, future research efforts should aim to validate intervention protocols across diverse populations and settings, with a focus on longitudinal follow-ups to assess the sustainability of pain relief benefits over time. Incorporating hypopressive exercises into patients' routines as part of a broader healthy lifestyle regimen may offer long-term benefits for chronic low back pain management. Thus, while the findings of this study supported the efficacy of HE in reducing NSCLBP, they could be used to conduct further research on the topic and help reduce the lack of information in the literature. This would benefit the quality of life of individuals affected by this symptom.

 

Conclusions 

 

    It is allowed to conclude that NSCLBP represents a public health problem that is currently affecting the quality of life and economy.

 

    After analyzing and discussing the studies included in this literature review, it can be identified that HE can be used as a non-invasive alternative to address this symptom affecting the population. Demonstrating in this study that a HE intervention has significant effects on the reduction of NSCLBP on the NRS scale and an improvement in the functionality of adults with NSCLBP, significantly reducing symptoms.

 

    However, more research is needed to understand the factors that may affect the effectiveness of these exercises when applied in different populations. Lastly, it is important to continue exploring new conservative treatment options to address this public health problem. Inviting healthcare professionals and governmental authorities to work together to develop programs or campaigns that promote prevention through healthy habits, an increase in physical activity, and ensuring access to conservative treatments for NSCLBP, thus improving the quality of life for the entire population.

 

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Lecturas: Educación Física y Deportes, Vol. 29, Núm. 315, Ago. (2024)