1.0 contact hour (60 min)
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Women's and Pelvic Health · 6 min read · September 27, 2026
From the course: Pelvic Floor Muscle Training After Childbirth and Twelve Years On: Two Randomized Trials · 1.0 contact hour
Listen while you read — the episodes from this course
Hypopressive Exercise for Postpartum Diastasis Recti Part 1 of 3 · 7 min
12-Year Follow-Up: Sling Surgery vs Pelvic Floor Therapy Part 2 of 3 · 8 min
Pelvic Floor Training: Short-Term Gains, Long-Term Reality Part 3 of 3 · 8 min
Do the gains from pelvic floor and abdominal training last? Read side by side, two papers answer part of that question. In a randomized trial published in the Brazilian Journal of Physical Therapy in 2026, Moreira and colleagues found that 12 weeks of supervised hypopressive exercise did not narrow postpartum diastasis recti more than no intervention, although women in the training group held bridge positions longer and reported less pelvic floor bother. In a twelve-year follow-up published in BJOG in 2025, van Oorschot and colleagues reported that most women first assigned to pelvic floor muscle training for moderate to severe stress urinary incontinence had gone on to sling surgery, and that the few who stayed with training alone reported the least improvement. Neither paper followed a postpartum training group for years, so whether early gains after childbirth hold up remains an open question.
Moreira and colleagues conducted the trial at the Federal University of Uberlândia in Brazil with 44 women who were between 45 days and 6 months after giving birth and had a separation of at least 20 mm between the rectus abdominis muscles. Half were randomly assigned to hypopressive training based on the Caufriez method, a sequence of postures combined with specific breathing and breath-holding, in two supervised 30-minute group sessions a week for 12 weeks. The control group received no intervention and was asked to avoid physical activity for the same period, so the comparison was between hypopressive training and doing nothing, not between hypopressive training and pelvic floor muscle training.
An ultrasound examiner who did not know group assignment measured the separation. It narrowed by a similar amount in both groups, and the authors reported no meaningful difference between them. They cite literature describing natural recovery over about 8 weeks after birth. Other outcomes favored the training group.
| Outcome at week 12 | Hypopressive group compared with control |
|---|---|
| Rectus abdominis separation (primary outcome) | Narrowed by a similar amount in both groups |
| Prone bridge hold | 34 seconds longer |
| Side bridge hold | 12 seconds longer on the right, 16 on the left |
| Pelvic Floor Bother Questionnaire (0 to 45, higher means more bother) | Fell from 8 to 3; control went from 6 to 7 |
| Body appreciation | Average increase of 30% compared with control |
The authors concluded that hypopressive training looked more relevant for function and symptoms than for closing the abdominal gap, and they wrote that management is better guided by muscle function and women's satisfaction than by gap closure alone.
Women attended about 72% of the 24 scheduled sessions, which the authors treated as a limitation and also as a realistic picture of the postpartum period. Baseline bother scores were low, so participants likely had mild symptoms, and the effect in women with more severe complaints remains untested. Other exercise, including pelvic floor muscle training, was not systematically monitored and may have contributed to the symptom changes. The researchers followed women for 12 weeks only, so their results cannot show whether any of the changes held after the program ended.
The original PORTRET trial was a Dutch nationwide multicenter randomized trial that assigned women with moderate to severe stress urinary incontinence to pelvic floor muscle training or to midurethral sling surgery as a first treatment, and it allowed women to cross over between treatments. Van Oorschot and colleagues mailed validated patient-reported questionnaires to 386 of the original participants an average of 11.9 years after randomization. Of those women, 184 (47.7%) returned the questionnaire: 84 originally assigned to physiotherapy and 100 to surgery.
Of the 84 responders assigned to physiotherapy, 73 (86.9%) had crossed over to surgery, up from 49.0% at 12 months in the original trial. The authors emphasize that these women were not encouraged to have surgery. With that much crossover, a comparison by original assignment mostly compared surgery with surgery, and among responders it showed no clear differences. The authors therefore added a post hoc analysis that grouped women by the treatment they actually received.
| Outcome at about twelve years (responders) | Initial surgery | Physiotherapy only (11 women) | Surgery after physiotherapy |
|---|---|---|---|
| Much or very much better | 87.0% | 36.4% | 86.1% |
| No incontinence symptoms | 70.0% | 36.4% | 79.5% |
| No leakage with activity, coughing or sneezing | 72.5% | 20.0% | 75.4% |
The same pattern held when all 386 women were included. The authors reported that physiotherapy before surgery added no benefit compared with surgery alone, and that 8 of 173 women who had a sling (4.6%) reported a re-operation, mostly for a surgical complication rather than recurrent leakage. They concluded that women with moderate to severe stress incontinence should be told these long-term figures and offered sling surgery even without prior physiotherapy.
For the women who did not respond, the authors carried forward each woman's 12-month status, which they described as probably the most favorable scenario for physiotherapy. Long-term adherence to training was never measured. The authors acknowledged that women who stopped may never have realized the benefit of training, and they also argued that stopping may itself signal limited benefit. The physiotherapy-only group was very small, and the treatment paths in the post hoc analysis were formed by the women's own choices rather than by randomization. Women with mild symptoms had been excluded from the original trial, and the authors raised the possibility that women who preferred surgery were more likely to enroll.
In the course, the disagreement is explained by who was studied and for how long, rather than by one paper being right. The Brazilian trial followed mildly bothered postpartum women with diastasis for three months, with no surgical option in the design. PORTRET followed women with moderate to severe stress incontinence for a decade, and those women could choose surgery at any point, so neither team tested the other's question.
Both author teams reported their clearest findings in patient-reported or functional outcomes rather than in the anatomy clinicians most often measure. Adherence was the weak point in both, and both author teams described variable adherence as a realistic feature of clinical practice.
The two papers support telling a postpartum patient that supervised hypopressive training improved abdominal endurance and reduced pelvic floor bother over 12 weeks compared with doing nothing. They do not support telling her that the training closes a diastasis faster than time does, or that pelvic floor training first improves a later surgical result. Discussing prognosis and weighing conservative against surgical options are physical therapist responsibilities; physical therapist assistants deliver the plan of care and report what they observe, including adherence.
In Moreira and colleagues' randomized trial, 12 weeks of supervised hypopressive exercise did not narrow the separation between the rectus abdominis muscles more than no intervention. Compared with the control group, women in the training group held prone and side bridge positions longer and reported less pelvic floor bother, and their body appreciation improved.
Neither paper answers this for postpartum women, because the Brazilian trial ended at 12 weeks. In van Oorschot and colleagues' twelve-year follow-up of women with moderate to severe stress urinary incontinence, most women first assigned to pelvic floor muscle training had chosen surgery, and those who stayed with training alone reported the least improvement. Adherence was not measured, and fewer than half of the invited women responded.
For women with moderate to severe stress urinary incontinence, van Oorschot and colleagues reported that physiotherapy before surgery added no benefit compared with surgery alone, and they recommended offering sling surgery even without prior physiotherapy. They made that recommendation for their own population rather than as a general statement about pelvic floor training.
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