The effects of a progressive exercise program with surface electromyographic biofeedback on an adult with fecal incontinence. (Case Report).

Fecal incontinence has been defined as the involuntary loss of bowel control sufficient to be considered a problem by the patient. (1) This condition may lead to an individual becoming housebound and reclusive because of social embarrassment. (1-5) Physicians do not routinely include questions regarding bowel continence in their interviews of patients, and patients do not readily report this condition to their physicians. (1-4)

Jorge and Wexner (3) reported that the prevalence of fecal incontinence is as high as 1.5% of the general population, with an estimated 3 million Americans affected. Women with urinary incontinence or pelvic organ prolapse are particularly susceptible to fecal incontinence. (1) Age may be a factor, as Johanson and Lafferty (4) reported that fecal incontinence is more common in women under 30 years of age than in the 31- to 50-year age range. They suggested that trauma during childbirth contributed to the higher prevalence rates reported for young women. (4) Although the cost for managing fecal incontinence is not known, the cost of medical care and rehabilitation for individuals with urinary incontinence in 1988 was estimated at $10.3 billion annually. (6)

The structure and function of the pelvic-floor muscles and the mechanisms of normal bowel control are important for understanding the impairments associated with fecal incontinence. The muscles of the pelvic floor have 3 major functions: (1) sphincter control, (2) support of the abdominopelvic organs, and (3) an assistive role in sexual responsiveness. (7) In general, the pelvic-floor muscles contract in response to rectal distention to inhibit defecation, and the muscles relax when rectal evacuation is desired.

As illustrated in the Figure, the deepest pelvic muscle group, the levator ani, consists of the iliococcygeus, pubococcygeus, and puborectalis muscles. This muscle group attaches anteriorly to the pubic bone and posteriorly to the coccyx. Some of the fibers of the puborectalis muscle sling around the anal canal and rectum at the anorectal junction, forming the anorectal angle. (7) When the puborectalis muscle contracts, it pulls the rectum anteriorly toward the pubis. This pulling action, in addition to the contraction of the anal sphincter muscle, constricts the anal canal, compressing the lumen. When the anal canal pressure exceeds that of the pressure in the rectum, fecal continence is maintained.

[FIGURE OMITTED]

The etiology of fecal incontinence is not completely understood. Some of the causes of fecal incontinence, however, include: mechanical trauma from obstetrical injuries or anorectal surgeries; pelvic-floor denervation from vaginal delivery; irritable bowel syndrome (IBS); laxative abuse; and neurological conditions, including cerebrovascular accident, multiple sclerosis, and neoplasms. (2,3) Specific complications of childbirth may predispose women to fecal incontinence. These complications include prolonged second stage of labor, delivery of an infant with high birth weight, and medical procedures such as the use of obstetrical forceps or episiotomy. (1-3,7)

Denervation of the pelvic floor during vaginal delivery is reported to be a major cause of fecal incontinence. (8) This denervation may occur if the pudendal nerve undergoes a stretch injury as the fetus' head passes through the vaginal canal during childbirth. The clinical name for this type of injury is postpartum pudendal neuropathy. Postpartum pudendal neuropathy may lead to damage or weakness of the external anal sphincter muscle and puborectalis muscle. The disruption of pelvic-floor function that follows may be transient and resolve within 2 months, but recovery does not always occur. (3,7) Snooks et al (9) reported transient nerve damage in 70% of a cohort of 50 women 2 months after vaginal delivery. In a 5-year follow-up of women who had a second child, however, the investigators found several cases of permanent damage of pelvic-floor muscles. Thus, multiple vaginal deliveries may result in cumulative damage to the pelvic-floor musculature and predispose a person for incontinence.

Irritable bowel syndrome is another major cause of fecal incontinence. Jackson et al (1) found that IBS was highly associated with fecal incontinence in women between the ages of 21 and 85 years. Excessive straining during defecation may lead to abnormal perineal descent and damage the pudendal nerve, leading to progressive pelvic-floor weakness. Several researchers (3,5,7,8) have suggested that a cycle of progressive denervation ultimately leads to fecal incontinence. Diarrhea, which is associated with IBS, may also increase the likelihood of fecal incontinence.

Surgical interventions such as anal repair or sphincter reconstruction may be used to correct fecal incontinence. More conservative approaches, however, such as combination of biofeedback with strengthening exercises, are typically attempted first. (1-3,5,6,10-21) An exercise regimen that is commonly suggested was first proposed by Kegel. (16) Kegel hypothesized that women with pelvic-floor muscle laxity or stress urinary incontinence could improve or restore their pelvic-floor muscle function and tone through exercise. The "Kegel exercise" he suggested for improving pelvic-muscle coordination and strength involved patients performing repeated contractions of their perineal muscles. (16) Kegel devised a biofeedback apparatus to serve as a visual aid for his patients, because he believed that many patients lacked an awareness of their pelvic-floor muscle function. He suggested that patients perform Kegel exercises in conjunction with biofeedback for 20 minutes, 3 times daily. More recent studies (11-18,21) have substantiated that the use of pelvic-floor muscle exercises combined with biofeedback is an effective intervention strategy for improving pelvic muscle control and alleviating fecal incontinence. In support of Kegel's hypothesis, performing pelvic-floor muscle exercises without biofeedback has been shown to be less effective than exercising with biofeedback. (12-14)

In addition to biofeedback and exercise, many individuals with fecal incontinence are able to manage their symptoms through proper diet and medications. People with fecal incontinence secondary to IBS, for example, often find that diet restrictions can be beneficial if certain foods and beverages exacerbate their symptoms. (22) Pharmacologic interventions also may be beneficial for improved bowel control. The use of antidiarrheal agents and anticholinergic medications often help to improve or restore normal bowel function. (2,3,5) Many of the symptoms of IBS are traditionally managed through the use of these medications. (22)

Although the combination of pelvic muscle exercises and biofeedback has been shown to lead to improvements in pelvic-floor muscle control and fecal continence, the specific details about what has been done within these intervention programs has not been well-defined. This has made it difficult for clinicians beginning to work in the area of incontinence to carry out a plan of care. The purpose of this case report is to describe a program for the rehabilitation of a client with fecal incontinence. Our approach reflected an integration of pelvic-floor muscle biofeedback, strengthening exercises, relaxation training, soft tissue techniques, and patient education.

Case Description

History and Medical Management

The patient was a 30-year-old woman who first experienced fecal incontinence immediately following the birth of her first child. Her labor and delivery were noted to be complicated and to involve an episiotomy and vacuum extraction of the baby. The baby's birth weight was 4.16 kg (9 lb 3 oz). The patient's past medical history included IBS for 8 years.

The patient's general practitioner referred her to a gastroenterologist at 8 weeks postpartum. The gastroenterologist prescribed Librax * and provided the patient with verbal instruction to perform pelvic-floor muscle strengthening exercises. The patient was seen for follow-up at 6-week and then 18-week intervals over a period of 10 months. The patient perceived no improvement in her control of her pelvic-floor muscles over this time, and the frequency and severity of her fecal incontinence was unchanged.

At 18 months postpartum, the patient decided to see a urogynocologist for a second opinion about treatment of her incontinence. Following an examination that included a medical history, a neurological assessment, and inspection and palpation of the pelvis and abdominal regions, the patient was referred for physical therapy. We selected this patient for the case report because she was typical of our patients with fecal incontinence.

Examination

One week prior to her initial visit, we mailed a questionnaire to the patient that asked her to report her perceived limitations in 6 categories of functional activities (Tab. 1). We designed the questionnaire for this patient based on the clinical experience of the primary author with patients with urinary incontinence and pelvic pain dysfunction and a literature review of the problems commonly associated with fecal incontinence. (1-6) This questionnaire provides the clinician with information regarding a patient's perceived functional limitation prior to intervention and at the time of discharge. Language for the questionnaire was adapted from the Guide to Physical Therapist Practice. (23) This questionnaire has not been tested for reliability or validity. The items within each category were rated on an ordinal scale from 0 to 5. A rating of 0 indicated that the patient perceived no limitations perceived, and a rating of 5 that her incontinence prevented participation in that activity. This questionnaire was used both as a pretest of how the patient believed her incontinence affected her lifestyle prior to therapy and as a posttest of the patient's perceptions following intervention. As Table I shows, the patient initially ranked social, occupational, and sexual domains as the categories most compromised by her fecal incontinence.

The patient was 18 months postpartum at the time of her initial examination. Her primary disability was her reluctance to dine out or attend social functions because of her incontinence. She reported incontinence of 1 to 2 drops of liquid feces one time per month and total fecal loss every other month (a total of 6 times a year). She complained of urgency to have a bowel movement that often required immediate use of the bathroom. She also reported having flatus incontinence and urinary losses during a hearty laugh, a strong cough, or a sneeze. She said that her physician had advised her to avoid eating lunch because she often experienced stomach cramping and was fearful that her cramping would result in fecal incontinence.

The examination began with an inspection and palpation of the perineum with the patient in a hooklying position. The patient complained of mild tenderness and hypersensitivity over the external surface of her healed episiotomy site. Palpation indicated a thickening of tissue at this location. Several irritable nodules were palpated along the episiotomy site extending toward her right ischial tuberosity. An irritable nodule is a soft tissue nodule that is palpated over soft tissue structures. Firm palpation over this nodule elicits a painful response from the patient. Internal palpation of the perineum revealed 2 irritable nodules at the episiotomy site. The patient stated that she had pain at this location for brief periods of time when she assumed a right side-lying position with her right leg extended. When asked to rate her pain from 0 (no pain) to 10 (excruciating pain), she rated her intensity of pain as 6.

To evaluate the reflex integrity of the perineal area, the patient was instructed to lie on her left side with her knees bent toward her chest while the anal sphincter reflex was tested. This is an examination test commonly used to assess the integrity of the pudendal nerve and the S2-4 segments of the spinal cord. (2,24) The typical response for a person with no known health problems is a contraction of the anal sphincter following a light stroke to the perianal region. For this patient, the anal sphincter response was difficult to elicit. Given this hypoactive response, an internal rectal assessment of pelvic-floor muscle integrity was carried out. The patient was instructed to pull her pelvic muscles upward and inward as if to hold back a bowel movement. Voluntary contractions of her puborectalis and external sphincter muscles were palpated, which indicated that the pudendal nerve and spinal segments of S2-4 were intact. The patient was screened for deficits in active range of motion and manual muscle testing for the lower extremities and trunk. A screen for sensation of light and sharp touch in the patient's lower extremities was performed. A standing postural assessment and reflex testing of bilateral Achilles tendons and patellae also were done. No deficits were noted. Similarly, no structural abnormalities (eg, diastasis recti) were present.

The patient was moved into a supine position with hips and knees in flexion for the evaluation of pelvic-floor muscle strength, endurance, and coordination. These variables were graded on a scale from 0 to 5, based on an internal vaginal palpation assessment described by Chiarelli (25) (Tab. 2). To avoid substitution of hip adductor muscles for pelvic-floor muscle contractions, the patient's knees were manually supported. During the performance of pelvic muscle contractions, the patient was instructed to perform pursed-lip breathing to avoid a Valsalva response. The patient was able to perform five 3-second contractions (at a grade of 2/5), but she showed poor pelvic-floor muscle endurance and was unable to fully isolate this muscle group. This was evidenced by the patient's tendency to hold her breath and adduct her hips during her contractions. Although internal vaginal palpation examination techniques have been developed to evaluate the integrity of the pelvic-floor muscles, reliability and validity studies have not yet been completed.

An EMG biofeedback assessment was carried out to examine the patient's resting muscle activity and her muscle endurance (mean EMG activity during a 60-second maximal contraction). This assessment involved the use of a laptop computer, the FlexiPlus Pelvic Muscle Rehabilitation System (FPMRS), ([dagger]) and an internal-dwelling recording electrode (Perry Anal Sensor ([double dagger])) inserted into the rectum to record activity of the pelvic-floor muscles. The anal sensor housed 2 active leads and a reference lead. This EMG system allowed the recording of raw EMG data at 1,000 samples per second, and an analog-to-digital converter provided a spectral analysis of the EMG signal as well as the root mean square (RMS) amplitude of the EMG signal. Raw EMG data were filtered using a 20- to 4,000-Hz band-pass filter, with a 60-Hz notch filter to eliminate 60-Hz artifact. The differential amplifier, with a common mode rejection ratio of >120 dB was used to further eliminate the noise from the leads.

The patient was instructed in the technique of inserting the internal recording electrode. Within the examination session and during each of 3 subsequent treatment sessions, the therapist rechecked the electrode placement to ensure accurate recordings of the pelvic-floor muscle activity. Electromyographic activity was displayed to the patient on the computer screen to provide her a visual cue used to signal the beginning of a contraction trial. In addition, an auditory tone generated by the computer was also used to prompt the patient to initiate her pelvic-floor muscle contraction at the appointed time. The patient assumed a left side-lying position during testing to promote comfort and to reduce the effects of gravity on the pelvic muscles.

The EMG evaluation began with a 60-second pre-exercise recording. The patient then practiced six 3-second contractions interspersed with five 12-second relaxation periods. After a brief rest period, six 12-second contractions were performed, interspersed with five 12-second relaxation periods. Following another brief rest, EMG data during a 60-second sustained contraction were recorded. The EMG evaluation was concluded with a 60-second post-exercise recording with the patient at rest.

The means, standard deviations, and coefficients of variation for the EMG activity of the pre-exercise, post-exercise, and maintained contraction periods were used to evaluate the patient's resting EMG activity and her pelvic-floor muscle endurance. These data were used to compare the patient's muscle activity from one treatment session to another. Improved control of pelvic-floor muscles was defined as an increase in EMG activity during the maintained contraction period and improved relaxation of muscles during the resting periods. These data are presented in Table 3. We know of no reliability or validity studies of EMG measurements of pelvic-floor muscles.

As the data show, the patient demonstrated relatively high levels of EMG activity of her pelvic-floor muscles during the pre- and post-exercise rest periods of her initial visit, suggesting excessive muscle activity at rest. During the EMG recordings, the patient was observed for compensatory movement patterns during periods of pelvic-floor muscle contractions. Initially, she was observed to hold her breath and moderately adduct her hips when performing pelvic muscle contractions. These observations were interpreted as evidence of compensatory patterns for weak pelvic-floor muscles. The patient was given continuous verbal feedback to avoid these compensations and to reinforce proper contractions of her pelvic-floor muscles during EMG recordings and all practice sessions.

In summary, during the first physical therapy session, the patient showed physical impairments that contributed to her disability. In addition, her fear of incontinence and the associated social consequences limited her ability to carry out her life roles. The patient's pathology, disability, functional limitations, and impairments are summarized in Table 4.

Intervention

Physical therapy was initiated following the examination on the first day and continued one day per month for 3 months. This frequency and duration were based on the patient's stated commitment to carrying out the recommendations at home and the amount of physical therapy that her health maintenance organization allowed. During each session, the patient performed therapeutic exercises and activities using the biofeedback as a training aid. Her physical therapy sessions also included passive stretching, massage, and ischemic compression interventions. A summary of the patient's physical therapy interventions is listed in Appendix 1.

During the first treatment session, after completing the EMG biofeedback initial assessment, passive soft tissue stretching and massage techniques were performed with the patient in a hooklying position. The therapist stretched the patient's episiotomy site lengthwise, once internally and 4 times externally over the healed incision. Deep transverse friction massage was performed internally through the introitus and externally over the healed tissue. (26) During the massage, the internal and external hyperirritable nodules were treated with manual ischemic compression. The reader is referred to Appendix 2 for the glossary of intervention terminology for the description of ischemic compression. This compression was maintained until the patient reported the hyperirritability had abated, after a minimum of 90 seconds. (27) The same procedure was used to treat the nodules medial and deep to the right ischial tuberosity, with the patient in a left side-lying position. In each case, these manual techniques were performed to patient tolerance.

Following the manual techniques, the patient was taught a set of home program exercises. The exercises were performed without a biofeedback unit because the patient wanted to keep her equipment costs low. Her exercise program consisted of phasic and tonic contractions performed in a left side-lying position with appropriate breath coordination. This involved 20 repetitions of 1-second contractions with 1-second relaxation and 90 repetitions of 5-second contractions with breath exhalation followed by 5-second relaxation. These exercises were to be repeated once in a side-lying position and 2 times each day in a sitting position. The entire time to complete these exercises was expected to be 45 minutes. The patient was instructed to contact the therapist if she found the exercise program to be too challenging or if her symptoms worsened. In addition to the exercise program, the importance of managing her diet and its potential benefits for her IBS were explained. (22) She was advised to keep a log about the intake of food that worsened her symptoms and to refer to the log rather than relying on her memory about which foods to avoid. She also was advised to eat small, frequent meals and to avoid alcohol, fatty foods, or spicy foods if they exacerbated her symptoms. (22)

One month after the initial visit, the patient reported no change in the frequency of her incontinence from her initial visit. She stated, however, that she was beginning to eat lunch again because her abdominal cramping had decreased, resulting in her being less fearful of associated fecal incontinence. She also reported that she was adhering to her exercise program.

The second treatment began in a way that was similar to the first treatment, with passive stretching, massage, and ischemic compression techniques over the patient's episiotomy site and right ischial tuberosity. These manual techniques were performed until a softening and lengthening of tissue seemed to be palpated. Following these techniques, the patient's pelvic-floor muscles were reassessed with EMG biofeedback. The data suggested that she continued to have high EMG activity of the muscles at rest. The patient also demonstrated her previous compensations of persistent breath holding and moderate hip adduction during pelvic-floor muscle contractions. She reported the activity to be very challenging and complained of general body tiredness following the reassessment.

The patient's treatment was modified in an attempt to more effectively address her high resting EMG activity. Biofeedback training was initiated in the side-lying position, which included performing diaphragmatic breathing with visual imagery of pelvic muscle relaxation. A brief description of the pelvic-floor muscles was provided to the patient, and she was asked to visualize these muscles relaxing as she breathed. This was followed by instruction in "elevator" exercises, as described by Noble. (20) This exercise was performed in 3 stages. First, the patient performed a succession of concentric pelvic muscle contractions, from a submaximal to a maximal level in a step-like manner. The patient then released her pelvic-floor muscles in a step-like manner until she had completely relaxed her pelvic-floor muscles. Second, an emphasis was placed on the patient coordinating pursed-lip breathing with a "pushing" of the pelvic-floor muscles. This "pushing" activity is assumed to result in a bulging of the pelvic-floor muscles in a caudal direction. Third, the patient performed a submaximal concentric pelvic-floor muscle contraction, which was intended to reset the resting position of the pelvic-floor muscles. During the biofeedback training session, following the elevator exercises, her EMG activity was reduced during resting periods.

The final therapeutic activity was performed without the use of biofeedback. This was a modification of a medical procedure called "balloon expulsion." (5) The patient was positioned in a side-lying position and was instructed to insert her rectal sensor. She was then instructed to "push out" the rectal sensor 3 times by means of gentle abdominal activity and relaxation of the pelvic-floor muscles. Although pursed-lip breathing was encouraged to prevent straining, the patient consistently showed a Valsalva response during this activity.

The patient's home program was progressed. The repeated 1-second contraction exercise for the pelvic muscles remained the same; however; the demands of the tonic contraction exercise were increased. In the side-lying position, the patient was instructed to increase the contraction time from 5 to 10 seconds, with a 10-second relaxation period after each contraction. To accommodate this higher demand, the number of repetitions was reduced from 90 to 45. In the sitting position, she continued with the 20 repetitions of the 1-second contractions and the 90 repetitions of the 5-second contraction/relaxation exercises, twice daily. The time allocated for this exercise routine was 45 minutes, exercising 15 minutes 3 times daily. The patient was informed that increasing the length of contractions from 5 to 10 seconds and working in a sitting position should help her to increase her pelvic muscle strength and endurance. The patient also was instructed to practice pushing out the rectal sensor 3 times daily in the side-lying position. She was told to avoid breath holding or Valsalva responses while practicing this activity.

The patient was also taught the soft tissue techniques of deep friction massage and ischemic compressions, and she was instructed to perform these techniques over the affected areas 2 to 3 times each week. In addition, she was asked to perform a 5-minute elevator exercise routine prior to her 10-second contraction/relaxation exercise routine in the side-lying position. She also was advised to purchase relaxation tapes to help reduce overall tension as is indicated for an individual with IBS. (22) The reader is referred to Appendix 1 for a summary of patient interventions.

Two months after the initial visit, the patient stated her abdominal cramping had become less frequent and intense over the past month. She was able to consistently eat lunch and was decreasing her Librax dosage (anti-cramping medication). She reported no change in her frequency of fecal incontinence and that she was adhering to her home program.

Examination revealed that the patient's soft tissue abnormalities had resolved. Palpation of the thickened tissue located over the episiotomy site seemed less dense and more pliable. The hyperirritable nodules that were palpable during the patient's last visit were not detected during the re-examination conducted during her third visit. Palpation for the hyperirritable nodules was performed internally over the episiotomy site and externally along the episiotomy site, and included palpation of the soft tissues extending toward the right ischial tuberosity. For this reason, all previous soft tissue interventions were discontinued. A reassessment of the patient's pelvic-floor muscle activity was carried out in the side-lying position. Recordings of EMG activity suggested that the patient's resting muscle activity was reduced and that she was able to further relax her muscle activity when concentrating. In addition, her EMG activity during phasic muscle contractions and the 60-second sustained muscle contraction occurred at greater amplitudes than in the previous session. These findings suggested improved motor control in both muscle relaxation and activation. Although the patient continued to demonstrate hip adduction substitution during pelvic-floor muscle contractions, she was able to perform her muscle contractions with only occasional breath holding. During the "push-out' exercise of the rectal sensor, the patient was able to expel the sensor without a compensatory Valsalva response; therefore, this exercise was also eliminated from her exercise program.

Biofeedback training was initiated with the patient in the side-lying position. As in the previous session, elevator exercises involving pelvic-floor muscles were performed from submaximal to maximal contraction levels. Coughing, which requires pelvic-floor muscle contraction, was added to the patient's training regimen. The patient then assumed a standing position to increase the demand of her exercise activities. She once again performed the elevator exercise routine, phasic and tonic muscle contractions, and maximal pelvic-floor contractions, concluding with the cough activity. The reader is referred to the glossary of intervention terminology in Appendix 2 for a description of this intervention

The patient's home program was progressed in both intensity and frequency. Her morning component, which was to be performed in the side-lying position, consisted of elevator exercises for 6 minutes followed by 20 repetitions of 1-second contractions/relaxation of the pelvic muscles and 30 repetitions of 10-second contractions/relaxation (a 16-minute exercise routine). In the afternoon, the patient was to perform her exercises in a sitting position. These exercises involved 20 repetitions of 1-second contractions/relaxation of the pelvic muscles followed by 45 repetitions of 10-second contractions/relaxation (a 15-minute exercise routine). In the evening, her program consisted of pelvic-floor exercises carried out in the standing position. The patient was to perform 20 repetitions of 1-second contractions/relaxation and 30 repetitions of the 10-second contractions/ relaxation (a 10-minute exercise routine). Thus, the patient's home program took a total of approximately 42 minutes per day. Kegel (16) advocated 20 minutes of exercise, 3 times daily (ie, 1 hour of exercise per day). She also was instructed to continually reassess and work on her pelvic-floor muscle relaxation by performing her relaxation exercises while at work in the sitting and standing positions and periodically throughout the day.

Three months after initial visit, the patient reported having no episodes of fecal incontinence over the past month. Her abdominal cramping had resolved. Consequently, she had discontinued taking Librax. She had also reduced her Imodium ([section]) dosage (antidiarrheal medication) to 1 to 2 times per week. Additionally, she reported that she performed her home program on a daily basis.

The only complaint the patient had was a recent onset of "groin" pain that occurred when she contracted her pelvic-floor muscles. Examination by palpation revealed a small hypersensitive nodule over the patient's right pubic ramus, near the insertion of her hip adductor. She was placed in the supine position, and ischemic compression techniques were performed. The patient reported the pain decreased following this soft tissue treatment. A final reassessment of the patient's pelvic-floor muscle activity was completed while she assumed a side-lying position. Improvement was noted in the EMG recordings at rest and during the 60-second sustained muscle contraction.

The patient's biofeedback training was initiated with her in a standing position. Training again included the performance of elevator exercises, phasic and tonic muscle contractions, and maximal pelvic-floor contractions in conjunction with the functional activity of coughing.

The home program was modified to include treatment for the nodule that was detected at her right hip adductor insertion. The patient was taught to perform ischemic compression techniques over the nodule 2 to 3 times each week until it resolved. Changing her exercise positions and increasing the number of exercise repetitions was again used to raise the intensity of her home program exercises. Her morning program was now to be performed in a sitting position. In addition, the patient was instructed to raise the number of 10-second contractions from 45 to 60. The number of 1-second contractions/relaxations remained at 20 repetitions. For the afternoon program, the patient was to progress from a sitting position to a standing position. Otherwise, the afternoon and evening exercises remained the same. The patient was reminded to consciously monitor her resting muscle tension throughout the day and to perform relaxation exercises as appropriate. She was given a relaxation cassette tape (1) to promote her overall relaxation. At this time, the patient was asked to fill out the questionnaire that reported her perception of functional limitations.

Outcomes

The patient reported an improvement in her lifestyle by the end of the intervention period (refer to Tab. 1 for questionnaire results). The patient's perception of her functional limitations showed a reduction in 5 of the 6 categories. Her ratings improved most in those areas she initially judged to be the most compromised: social, occupational, and sexual domains.

The patient reported having no episodes of fecal incontinence during her last month of therapy: She said that she engaged in social and work-related activities with greater confidence and comfort and that her physical relationship with her spouse was also much improved because of her increased self-assurance.

The patient said she had gained the confidence to return to eating 3 meals a day because she no longer experienced abdominal cramping after mealtime. She discontinued taking her prescribed anticramping medication (Librax) and decreased her dosage of Imodium from once daily to 1 or 2 times per week. The reduction in her symptoms and medications was meaningful for her. She was more willing to take part in work and social functions involving meals. The patient also had begun to eat in a healthier fashion. She avoided caffeinated beverages and had a low-fat diet. She identified cold cuts as a food group to avoid because she believed that cold cuts exacerbated her symptoms. This suggested she had benefited from the educational aspects of the intervention plan.

The patient's control of her pelvic-floor muscles showed consistent improvement throughout her physical therapy intervention. Overall improvements included greater EMG amplitude during the sustained muscle contraction time and decreased muscle activity at rest (refer to Tab. 3 for EMG data). The patient's pelvic muscle strength improved from an initial grade of 2/5 to 3/5. In terms of endurance, the patient was initially able to perform 5 repetitions of 3-second muscle contractions before fatiguing, but following intervention, she was able to perform seven 10-second contractions. In addition, she showed far less compensatory contraction of hip adductor muscles and breath holding during her exercises.

The soft tissue nodules and thickened tissue that had been present in the region of the episiotomy site at the time of the patient's initial visit were absent by the end of intervention. The patient's initial report of episiotomy pain, which she had rated as 6/10, had completely resolved. The only soft tissue abnormality present was a mildly uncomfortable nodule that had developed near the patient's right hip adductor muscle insertion. This may have resulted as an overuse syndrome, as the patient tended to strongly contract this muscle group along with her pelvic-floor muscles when performing her exercises.

Four months following the conclusion of the intervention program, the patient was contacted by telephone. She stated that she had experienced only "minor" fecal incontinence that was related to stress at work. Otherwise, the patient was pleased with the intervention program.

Discussion

The patient's fecal incontinence and associated disorders were reduced following the physical therapy intervention program. Our treatment strategy was based on a combination of patient education, pelvic-floor muscle strengthening exercises, relaxation training with the use of biofeedback, and soft tissue techniques. We believe that each of these components played an important role in promoting a successful outcome. First, a major requirement for any successful intervention is patient knowledge and dedication to the intervention plan. We emphasized to the patient that education and adherence to a home program were important elements of her treatment plan. We had limited ability to see the patient over the 3 months that she was engaged in therapy. A large part of the treatment plan involved a demanding home program of exercise, self-monitoring, relaxation exercises, and attention to dietary habits. We believe that teaching the patient general dietary guidelines and providing guidance and training in strengthening exercises, soft tissue and relaxation techniques, and functional training were critical components of the treatment outcome. This patient was well motivated and committed to her home program. Without proper education and willingness of the patient to adhere to the program, we doubt that our program would have been successful.

Second, the patient's pelvic-floor muscles were targeted as the focus for strength and endurance exercises. Phasic and tonic muscle contractions were used to specifically train and strengthen both fast- and slow-twitch muscle fibers. We believe that the progression of the exercise program from side-lying and sitting positions to standing positions created a greater challenge of pelvic muscle strength and endurance as the patient exercised against the effects of gravity. In addition, she was challenged to increase her duration of muscular contractions from 5 seconds to 10 seconds. We believe that the progressive position changes, increased duration of muscular contractions, and increase in repetitions helped the patient learn to contract her muscles quickly and forcefully and to maintain a strong pelvic muscle contraction to prevent fecal losses.

We hypothesize that pelvic-floor muscle strength and function have the potential to improve because this striated muscle group is under volitional control and can be affected through the same basic treatment techniques commonly used by physical therapists. The location of the pelvic-floor muscles inherently adds to the difficulty of retraining a weak muscle that is not readily visible or palpable to either the patient or the physical therapist. As a result of muscle weakness, the patient may inadvertently substitute a variety of other muscles such as hip adductors, gluteal muscles, or abdominal muscle groups in an attempt to contract pelvic-floor muscles. We believe that it is important for the patient to learn to isolate and strengthen the pelvic-floor muscles. Although pelvic-floor muscle control is not ordinarily something of which a person is conscious, increased awareness of this area through patient education, biofeedback, and muscle re-education techniques might assist in restoring normal bowel function. Improving the voluntary control of this muscle group is likely to be important in promoting the restoration and preservation of fecal continence.

One type of motor control exercise that appeared to be particularly useful for this patient was the training of pelvic-floor muscles through a technique of pushing out a rectal sensor. The ability to pass stool without excessive strain is important to prevent damage to the pelvic-floor muscles. It is feasible that a patient who demonstrates high pelvic-floor muscle activity at rest may excessively strain and use a Valsalva maneuver to pass stool to overcome the resistance that is present in overactive rectal muscles. Initially, this patient was inappropriately using a Valsalva maneuver to push out the rectal sensor. Verbal feedback and an emphasis on pursed-lip breathing were used to help the patient learn to push the sensor out without straining. This required effective use of her pelvic-floor and abdominal muscles. The patient was able to learn this technique between the second and third treatment sessions.

Surface EMG biofeedback with the internal-dwelling electrode was used as means of helping the patient isolate and improve her pelvic-floor muscle control. Augmented feedback or biofeedback is believed to be beneficial in motor training when individuals lose intrinsic feedback mechanisms of control. (28,29) Several studies 912-14,16,21,28) have shown that the use of biofeedback augments a person's ability to more effectively learn how to contract and relax the pelvic-floor muscles. Burgio et al, (21) for example, showed that a group of subjects with urinary incontinence who were trained in pelvic-floor exercises with biofeedback and verbal feedback had greater improvements in strength and selective control of the pelvic-floor muscles than a group receiving only verbal feedback. It follows that the use of biofeedback may also be a useful strategy for managing patients with fecal incontinence. In addition to her instruction in soft tissue and self-monitoring techniques, relaxation training, and guidelines for dietary management, our patient was given verbal instruction to perform pelvic-floor muscle exercises by her physician, but she reported improved bowel control only after she began training with surface EMG biofeedback.

In addition to attempting to promote improved muscle contraction, we used biofeedback to help the patient learn to appreciate and monitor her resting muscle activity. Once excessive muscle activity at rest was identified, the patient was able to use relaxation techniques to reduce this excessive muscle activity. Following elevator exercises, the patient's pelvic-floor muscle EMG signal was reduced during periods of rest. In addition, the patient used a relaxation tape to work on progressive muscle relaxation techniques, diaphragmatic breathing, and imagery to further reduce her resting muscular activity.

Although EMG biofeedback can be a useful tool for recording muscle activity levels during periods of rest and contraction, it has limitations. For example, noise or cross talk from adjacent muscles can confound the electrical signal. Furthermore, EMG biofeedback cannot discern strength grades. The collection of EMG data and its interpretation go beyond the scope of this article, and the reader is referred to Lawrence and De Luca (30) and Enoka's (31) work for a comprehensive overview.

Lastly, our program emphasized a number of soft tissue techniques, including transverse friction massage, (26) ischemic compression technique, (27) and general tissue stretching. These techniques were used to treat painful nodules, to reduce the pain over the episiotomy site, and to stretch thickened soft tissues. The initial pain the patient had over the episiotomy site may have contributed to her inability to use her pelvic-floor muscles effectively. The reduction of her pain may have allowed the patient to better coordinate contraction and relaxation of her pelvic-floor muscles, thus contributing to her improved bowel control.

We used a combination of intervention components, including patient education, retraining of muscle control, relaxation with biofeedback, and soft tissue techniques to provide the patient a comprehensive and integrated form of intervention for fecal incontinence. We were not able to identify whether one of these elements played a larger role in the outcomes than the others. Further study may determine whether the entire program or separate aspects of the program are successful. Areas of needed research include confirming the reliability of data obtained with internal pelvic-floor manual muscle testing, determining the type of pelvic-floor muscle contractions and relaxation techniques most effective for re-educating pelvic-floor muscle activity, critical analysis of the effectiveness of soft tissue techniques, and determining which intervention strategies are most effective in managing fecal incontinence.

Appendix 1.
Summary of Patient Interventions

Initial Visit  1. Passive stretching of episiotomy site, transverse
                  friction massage and ischemic compressions:
                  patient in hooklying position followed by left
                  side-lying position.
               2. Patient education for exercise adherence,
                  exercise training, and dietary guidelines.
               3. Home exercise program of pelvic muscle exercises:
                  20 repetitions of 1-second contractions and 90
                  repetitions of 5-second contractions with breath
                  coordination. Performed in side-lying position
                  once a day and repeated in sitting position twice
                  a day for the  next month.

Second Visit   1. Soft tissue techniques continued.
               2. Electromyographic (EMG) biofeedback reassessment
                  was performed with the patient in left side-lying
                  position. These data were compared with the initial
                  EMG recordings.
               3. Pelvic-floor muscle relaxation training with
                  biofeedback with patient in left side-lying
                  position. Training included diaphragmatic breathing
                  and visual imagery of pelvic muscle relaxation.
               4. Elevator exercises were performed with biofeedback
                  with patient in left side-lying position.
               5. Training pelvic muscles to push out the rectal
                  sensor using pursed-lip breathing techniques. This
                  activity was performed in the left side-lying
                  position and without biofeedback.
               6. Home exercise program included a 5-minute elevator
                  exercise routine and 20 repetitions of 1-second
                  contractions and 45 repetitions of 10-second
                  contractions with breath coordination daily in
                  side-lying position. Exercises in sitting position:
                  20 repetitions of 1-second contractions and 90
                  repetitions of 5-second contractions with breath
                  coordination, twice daily.
               7. Home program also included teaching the patient to
                  perform selfi-ischemic compression techniques 2 or 3
                  times per week. She was instructed to practice
                  pushing out the rectal sensor 2 or 3 times, daily.
                  Patient was encouraged to periodically perform
                  elevator exercises while sitting at work. Relaxation
                  tapes were advised for the promotion of overall
                  relaxation.

Third Visit    1. Soft tissue techniques were discontinued because
                  reassessment revealed soft tissue abnormalities had
                  resolved.
               2. Electromyographic biofeedback reassessment was
                  performed with the patient in the left side-lying
                  position. This third collection of data was compared
                  with the initial and previous EMG recordings.
               3. Push-out exercise of the rectal sensor was
                  discontinued. Reassessment revealed the patient was
                  able to expel the sensor without compensatory
                  Valsalva maneuver.
               4. Elevator exercises and maximal pelvic muscle
                  contractions during functional cough activities were
                  performed with the patient in the left side-lying
                  position.
               5. Strength training session for pelvic muscles was
                  performed with biofeedback in the standing position.
                  This included performing elevator exercises, phasic
                  and tonic muscle contractions, and functional cough
                  activities.
               6. Home exercise program: morning exercises in the
                  side-lying position consisted of a 6-minute elevator
                  exercise routine, 20 repetitions of 1-second
                  contractions, and 30 repetitions of 10-second
                  contractions with  breath coordination. In the
                  afternoon, exercises were performed in the sitting
                  position, 20 repetitions of 1-second contractions
                  and 45 repetitions of 10-second contractions with
                  breath coordination. Evening program: exercises
                  performed in standing position included 20
                  repetitions of 1-second contractions and 30
                  repetitions of 10-second contractions with breath
                  coordination.
               7. Home program: the patient was also instructed to
                  perform elevator exercises periodically throughout
                  the day while at work in the sitting and standing
                  positions.

Discharge      1. Palpation reassessment revealed a small
  Visit           hypersensitive nodule over the patient's right pubic
                  ramus, near insertion of hip adductor muscle.
               2. Ischemic compression techniques were performed over
                  the hypersensitive nodule with the patient
                  positioned supine.
               3. Electromyographic biofeedback reassessment was
                  performed with the patient in the left side-lying
                  position. This  last collection of EMG recordings
                  was compared with all the previously collected EMG
                  data.
               4. Strength training session for pelvic muscles was
                  performed with biofeedback in the side-lying and
                  standing positions. In the side-lying position, the
                  patient performed elevator exercises and functional
                  cough activities. In the standing position, the
                  training session included elevator exercises, phasic
                  and tonic muscle contractions, and functional cough
                  activities.
               5. Her discharged therapeutic exercise routine included
                  20 repetitions of 1-second contractions and 60
                  repetitions of 10-second contractions with breath
                  coordination, 3 times a day. She was instructed to
                  perform these exercises once in a sitting position
                  and twice in a standing position.
               6. Home program: the patient was instructed to perform
                  ischemic compressions over the hypersensitive nodule
                  located near her right hip adductor muscle
                  insertion, 2 to 3 times per week until it resolved.
                  She was also instructed to self-determine pelvic
                  muscle tension twice a day and to perform elevator
                  exercises to release this muscle tension. She was
                  instructed to perform elevator exercises
                  periodically throughout the day while at work in the
                  sitting and standing positions. Additionally, the
                  patient was given a relaxation cassette tape to
                  promote her overall relaxation.

Appendix 2.

Glossary of Intervention Terminology

Passive stretching: To stretch noncontractile tissue, the episiotomy site was stretched for 30-second intervals along its length. This was repeated 2 to 4 times.

Deep transverse friction massage: This is a deep massage using heavy pressure that is performed at right angles to the long axis of the muscle fibers or tendons, and it is performed over a specified location for approximately 2 minutes, as described by Cyriax. (26) This technique is used for the purpose of remodeling tissue.

Ischemic compressions: A nodule is compressed manually with light to moderate force for 90 seconds, as described by Travell and Simons. (27) This technique is used for the purpose of decreasing the sensitivity in hypersensitive nodules.

Electromyographic biofeedback evaluation and reassessments with the use of a one-channel internal-dwelling electrode: The protocol for this technique is described in the examination section. Every session included recordings of the resting preactivity period, followed by contraction and relaxation periods.

Pelvic-floor muscle phasic concentric exercises: This refers to the patient performing twenty 1-second contractions with 1-second relaxations.

Pelvic-floor muscle tonic concentric exercises: This refers to the patient performing 5-second contractions as the patient performs pursed-lip breathing, using a 5-second relaxation period. The pelvic-floor muscle tonic contraction should ultimately progress toward a 10-second contraction with appropriate breath coordination and a 10-second relaxation period.

Elevator exercises: These are graded exercises that emphasize concentric contraction, progressive relaxation, and coordination of breathing. Noble (20) described this pelvic-floor muscle exercise as analogous to an elevator. As an elevator would ascend from one floor to another up to the top "fourth floor," the pelvic-floor muscle should concentrically contract, increasing in its force of contraction at each ascending level. When the elevator has reached the top level, this would be the equivalent to a maximal pelvic-floor contraction. Noble then described the elevator making smooth transitions to lower floor levels; at this point, the pelvic-floor muscles would progressively relax. Descending to the "basement level" is Noble's analogy for a pushing technique that is performed with appropriate pursed-lip breath control. Strain or Valsalva response is avoided. This exercise routine is concluded with a concentric pelvic-floor muscle contraction to the "ground floor" level. (20)

Pushing against resistance: To accomplish this activity; the patient is instructed to insert the rectal sensor and then "push out" the rectal sensor by means of muscular control without using forceful exhalation.

Maximal pelvic-floor concentric contractions: These are exercises where the patient needs to sustain a maximal concentric contraction during functional activities (eg, coughing and position changes).

Table 1.
Ordinal Ratings for Six Categories of Functional Activities
Obtained With Questionnaire of Perceived Limitations (a)

                                              Pre-       Post-
                                              treatment  treatment
Activities of Daily Living                    Rating     Rating

Family and home responsibilities (eg,         1          0
  laundry, shopping, child care, yard work)

Recreation (ie, hobbies [eg, gardening],      1          1
  exercising with weights, or aerobic
  exercising [eg, running, bicycling])

Social activities (eg, dining out, going to   4          1
  parties, dancing, walking in neighborhood
  or in community, traveling)

Occupation (eg, lifting, carrying, reaching,  3          0
  stooping, squatting)

Self-care (eg, getting into and out of bed/   1          0
  chair/car, dressing, showering, sleeping,
  walking around home, stair climbing)

Sexual behavior (eg, sexual activity as it    3          1
  relates to patient's condition)

(a) The questionnaire was used to identify the patient's perceived
functional limitations prior to intervention and at the end of the
final day of therapy. Ratings: 0=no limitations, 1=slight limitations,
2=minimal limitations, 3=moderate limitations, 4=maximal limitations,
5=disabled.
Table 2.
Pelvic-Floor Muscle Strength Assessment (a)

Grade                 Definition

0=no contraction      Muscle contraction is absent.

1=trace contraction   A feeble squeeze is elicited after
                        providing a quick stretch to the
                        pelvic-floor muscles.

2=poor contraction    A thin band of tissue mildly exerts
                        pressure around the examiner's
                        fingers, generating a weak contraction.

3=fair contraction    Described as a "lift," an inward movement
                        of the perineum is appreciated.

4=good contraction    Good hold with "lift." Contraction is
                        repeated a few times.

5=strong contraction  Good "lift," repeatable.

(a) The standardized strength assessment scale from 0 to 5 was
applied to the pelvic-floor muscles. Characteristics for each
muscle grade according to Chiarelli. (25)
Table 3.
Electromyographic (EMG) Activity During Initial and Discharge
Treatments (a)

                                               Initial Visit

                                               [bar]X  SD    CV

Pre-exercise resting EMG activity ([micro]V)   8.20    1.38  0.17

EMG activity ([micro]V) during an active
  muscle contraction                           9.10    2.00  0.22

Post-exercise resting EMG activity ([micro]V)  6.65    1.18  0.17

                                               Final Visit

                                               [bar]X  SD    CV

Pre-exercise resting EMG activity ([micro]V)    5.38   0.41  0.07

EMG activity ([micro]V) during an active
  muscle contraction                           17.90   2.00  0.11

Post-exercise resting EMG activity ([micro]V)   2.86   0.62  0.21

(a) Comparisons were made between EMG activity during the
pre-exercise and post exercise periods and during the 60-second
sustained pelvic muscle contraction.
CV=coefficient of variation.
Table 4.
Summary of Pathology, Including the Patient's Disabilities,
Functional Limitation, and Impairments

Pathology     Irritable bowel syndrome with recent onset of
                fecal incontinence subsequent to childbirth.

Impairments   Pain upon palpation over the hypersensitive nodules.

              Pain at episiotomy site when the patient assumed a
                right side-lying position with the right leg extended.

              Weakness of the pelvic-floor muscles.

              Compensatory patterns of movement present during
                pelvic-floor muscle contractions.

              Impaired muscle function as evidenced by the patient's
                reduced electromyographic biofeedback signal during
                pelvic-floor muscle contractions. The patient also
                displayed elevated electromyographic activity levels
                of her pelvic-floor muscles during periods of rest.

              Impaired muscle function: Valsalva response present
                during "push" activities in the relaxation phase for
                pelvic-floor muscles.

Functional    Inability to maintain and control fecal continence.
limitation

Disabilities  Decreased social interactions: patient avoided eating
                lunch at work and limited herself from dining out or
                attending social functions.

              Limited sexual intimacy with her spouse.

              Reduction in overall activity level.

              Emotional overlay: psychological stress due to need to
                wear protective undergarments rather than more
                conventional clothing.

* Roche Pharmaceuticals, Roche Laboratories Inc, 340 Kingsland St, Nutley, NJ 07110-1199.

([dagger]) The Computerist Inc, 8 Fourth Ln, PO Box 4131, Chelmsford, MA 01824.

([double dagger]) SRS Medical Systems Inc, 14950 NE 95th St, Redmond, WA 98050. ([section]) McNeil Consumer Healthcare, Div of McNeil-PPC Inc, Fort Washington, PA 19034.

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SW Coffey, PT, BSPT, is Part-time Faculty Member, Program in Physical Therapy, New York Medical College, Valhalla, NY. She also is Owner of Coffey Physical Therapy, 99 Kennard Rd, Mahopac, NY 10541 (USA) ([e-mail]). Address all correspondence to Ms Coffey at the second address.

E Wilder, PT, MAPT, is Associate Professor, Department of Physical Therapy, Saint Louis University, St Louis, Mo.

M Majsak, PT, EdD, is Program Director and Associate Professor, Program in Physical Therapy, New York Medical College.

R Stolove, PT, MAPT, is Director of Clinical Education, Program in Physical Therapy, New York Medical College.

L Quinn, PT, EdD, is Associate Professor, Program in Physical Therapy, New York Medical College, Valhalla, NY.

Concept/idea/research design and writing were provided by Ms Coffey. Writing was provided by Ms Wilder, Dr Majsak, Ms Stolove, and Dr Quinn.

This article was submitted August 18, 2000, and was accepted March 11, 2002.