Valsalva maneuver

Author: Aditya Mahajan

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Valsalva maneuver refers to a specific breathing technique used in strength training and characterized by a forced exhalation against a closed glottis. During this forced exhalation, Intra-abdominal pressure (IAP) and Intra-thoracic pressure (ITP) are elevated due to the contraction of the diaphragm and intercostal muscles and obliques to some extent.
What is Intra-Abdominal Pressure?

F5F5D94F-05BB-41F1-8A35-9B6CFD368A87Intra-abdominal pressure (IAP) basically refers to the pressure inside the abdomen cavity and is thought to provide extrinsic stabilization of the spine. IAP is elevated in response to muscular activities such as:
➢ Strength Training:
There exists a positive correlation between the weight lifted and IAP. The IAP increase with the increase in the load lifted. Generally, peak rise in IAP occurs during the acceleration phase of the lift.
➢ Other physical activities:
IAP rises slightly with the increase in abdominal activity/contraction. Therefore, physical activities like walking, running, jumping etc increase the abdominal activity and thus IAP.
Benefits of Valsalva maneuver:
1. Unloading and stabilization of spine: It was speculated that increase in IAP during Valsalva maneuver could unload the spine both directly (by pressing upwards on the rib cage via diaphragm) and indirectly (by generating an extensor moment on the lumbar spine that decreases the back-muscle activities). However, the role of IAP in unloading and stabilizing the spine is posture and task-dependent. For example:
a. Valsalva maneuver while standing without lifting may increase the load on the spine.
b. In forward lifting tasks, IAP significantly reduces the load on the spine.

Together VM and contraction of the abdominal muscles reduces the compressive load imposed on the spine and result in more stable posture and a better alignment of the vertebrae during the strenuous exercise which can potentially lower the risk for low back injury.

2. Specific muscle activation: Previous work shows that Valsalva maneuver in a combination of weightlifting belt at the same time can potentially increase the muscle activation in erector spinae and the bigger abdominal muscles which in turn can reduce lower back and lumbar spine injury risks.

3. Protect against cerebrovascular damage: IAP increases intra-thoracic pressure (ITP) causing an increase in systolic pressure. It was earlier speculated that high systolic pressure may damage the arteries, however, studies have suggested that increase in ITP (during Resistance exercise with Valsalva Maneuver) is transmitted directly to Intra-Cranial Pressure (ICP) i.e. the pressure surrounding the arteries. Since Arterial pressure and ICP are elevated equally, thus there are no changes observed in Cerebrovascular transmural pressure (CVTMP; equals to the systolic pressure minus ICP).
On the other hand, Resistance exercise without Valsalva Maneuver results in a significantly greater increase in CVTMP.
Thus, it is concluded that VM during RE may prevent against cerebrovascular damage during lifting.

Risk factors for Valsalva maneuver:
The dramatic increase in the heart rate and blood pressure: Depending on the duration of maneuver, increase in ITP simultaneously leads to decreased venous return and potentially reduced cardiac output. This result in an increase in Heart rate to maintain cardiac output and vasoconstriction to maintain blood pressure. As the pressure on the chest is released, increase in venous return accompanies, resulting in an increase in cardiac output and dramatic increase in blood pressure, that may require minutes to return to baseline. This could have following implications:
1. The reduced cardiac output during VM may induce symptoms of light-headedness or dizziness.
2. Safety of VM needs to be established in patients with heart diseases. Elevated blood pressure may result in symptoms of myocardial ischemia.

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References:
1. Williams, Mark A., et al. “Resistance exercise in individuals with and without cardiovascular disease: 2007 update.” Circulation116.5 (2007): 572-584.
2. Arjmand, N., and A. Shirazi-Adl. “Role of intra-abdominal pressure in the unloading and stabilization of the human spine during static lifting tasks.” European Spine Journal 15.8 (2006): 1265-1275.
3. Björk, Julia. “The effect of a weightlifting belt and the use of Valsalva maneuver on power output and velocity in a squat.” (2017).
4. Nachemson, Alf L., Gunnar BJ Andersson, and Albert B. Schultz. “Valsalva Maneuver Biomechanics: Effects on Lumbar Trunk Loads of Elevated Intraabdominal Pressures.” Spine 11.5 (1986): 476-479.
5. Haykowsky, Mark J., et al. “Resistance exercise, the Valsalva maneuver, and cerebrovascular transmural pressure.” Medicine & Science in Sports & Exercise 35.1 (2003): 65-68.

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