Pelvic floor muscle rehabilitation using biofeedback.
Key Words: Pelvic floor muscle training, biofeedback therapy, electromyogram, vaginal and rectal sensors, pelvic floor muscle electrical stimulation.
The pelvic floor contains a group of muscles pelvic floor muscles (PFMs)--that extend from the symphysis pubis (anterior) to the back (posterior) of the bony pelvis, forming a hammock that supports the pelvic organs (Newman & Wein, 2009). The PFMs are composed of the levator ani group and includes the pubococcygeus, puborectalis, and ileococcygeus muscles (see Table 1 and Figure 1). PFMs are composed primarily of skeletal muscle that differs from other skeletal muscle because they not only provide support for all the organs of the pelvis, they have a higher resting muscle tone so as to support the external urinary sphincter. PFMs are entirely under voluntary control and play an important role in maintaining continence, and can become weakened from pregnancy and childbirth, lack of use, a decrease in the hormone estrogen, aging, surgery, and injury (Maserejian et al., 2014).
Pelvic Floor Muscle Exercises
Weakness in PFMs can lead to problems with both bladder and rectal support because fecal and urinary continence are difficult to maintain without adequate strength and support. Correcting PFM weakness through muscle rehabilitation is helpful in treating urinary incontinence (UI) if lack of pelvic support is the causative factor. Increasing functionality of PFMs has also been shown to help with alleviating urinary urgency and frequency, and has been linked to activation of the sacral micturition center, which in turn results in urinary urge inhibition (Moore et al., 2013; Wyman, Burgio, & Newman, 2009).
Pelvic floor muscle training (PFMT) is based on the presumption that exercising can both increase the capacity of existing muscle and hypertrophy the muscle (aerobic and anaerobic capacity); thus, strong repeated exercise increases muscle bulk, and prolonged muscle contraction at moderate intensity increases endurance. Hypertrophy of the muscle might take weeks to months before it is apparent (McLean et al, 2013). In addition to PFMT with biofeedback, clinicians with expertise in behavioral treatments for UI and related lower urinary and pelvic symptoms add other interventions, including bladder training with urgency inhibition or suppression, and diet and fluid management to maximize outcomes (Greer, Smith, & Arya, 2012; Newman & Wein, 2013; Wyman et al, 2009).
Biofeedback (BF) therapy is a technique in which physiological activity (neuromuscular and autonomic activity) is monitored, amplified, and conveyed to the patient (feedback) as visual or acoustic signals (Newman & Wein, 2009). As a result, BF gives an individual immediate feedback about normal body processes of which they may not be aware. It provides instantaneous information to the patient about the status of the PFM. While some consider BF part of complementary therapy, it is also viewed as an adjunct to PFM rehabilitation for persons with lower urinary tract symptoms (LUTS) (e.g., irritative and emptying symptoms) and pelvic floor dysfunction (e.g., pelvic pain). Figure 2 outlines a Decision Tree for instituting PFM rehabilitation for LUTS, neurogenic bladder dysfunction, and pelvic pain.
BF therapy that involves neuromuscular training is an instrument-based learning process based on "operant conditioning" techniques. The governing principal is that any behavior (whether it is a complex maneuver, such as eating, or a simple task, such as muscle contraction), when reinforced, its likelihood of being repeated and perfected increases.
One goal of BF-assisted behavioral treatment of LUTS is to alter physiologic responses of the detrusor and PFM that mediate urine loss and cause urinary urgency, such as with individuals experiencing urgency UI and/or overactive bladder (OAB). BF can also be used to teach persons new skills for preventing UI, assist them in relearning previous bladder control behaviors, and how to relax a muscle that may be in spasm. Therefore, BF can be a vital component of a behavioral program to treat stress and urgency UI (Hay-Smith, Henderschee, Dumoulin, & Herbison, 2012; Herderschee, hay-Smith, Herbison, Roovers, & Heineman, 2011; Newman & Wein, 2013).
Biofeedback is also used in patients with bowel dysfunction, such as fecal (anal) incontinence (FI) (Heymen et al., 2009; Norton & Cody, 2012). In these patients, the goal is to strengthen the anal sphincter to restore a normal pattern of defecation. In patients with dyssynergic defecation and loss of stool, the goal of neuromuscular training is two-fold: 1) to correct the dyssynergia or incoordination of the abdominal, rectal, puborectalis, and anal sphincter muscles to achieve a normal and complete evacuation; and 2) to enhance rectal sensory perception in patients with impaired rectal sensation (Markland et al., 2008).
Use of BF in Specialty Clinical Practice
Applying BF in a specialty clinical practice (e.g., urology, urogynecology) is a dynamic process because there is transference of information to the patient. This process begins with a pelvic floor muscle assessment (see Figure 3). The patient learns to control bladder, sphincter, PFMs, and intra-abdominal pressure by responding to visual or auditory signals generated through the activity of an internal physiologic process. As previously noted, the advantage for both the patient and the clinician is that information is immediate and can be interpreted simultaneously, allowing the patient to control responses of which they may have little or no knowledge or awareness. For example, BF can provide motivation to patients who may be frustrated over inability to isolate PFMs or who lack sensation of muscle contraction.
A patient education handout that provides information on BF (see Figure 4) may be given to all patients prior to treatment. BF therapy is most useful when the patient is motivated, wants to be actively involved in their therapy, can follow directions, and when there is a readily identified and measurable muscle response. The clinician, though, is integral to a BF-assisted PFM rehabilitation program because more intensive supervised programs taught by health professionals have been shown to be better than self-directed programs (Moore et al., 2013). This service model is used in many urology practices or pelvic floor centers, which employ trained health care specialists (usually registered nurses, nurse practitioners, physical therapists). In these types of specialty practices, patients who receive BF and other conservative treatment have more contact with the health care provider and receive more intensive treatment. Contact and interaction with a pelvic floor specialist can be an important component of BF-assisted PFMT. A 2011 Cochrane review noted that BF may add benefit to PFMT, but the observed effect could well be related to another variable, such as the amount of clinician contact rather than the actual BF (Herderschee et al., 2011, 2013). The International Consultation on Incontinence (ICI) Committee on Adult Conservative Treatment (Moore et al., 2013) also noted that it is not known if regular visits with the clinician vs. the actual treatment using BF is more effective.
Figure 3. Pelvic Floor Muscle Assessment * Prior to examination, the patient should have voided. * Have the participant undress from the waist down and lie supine (women with hips and knees flexed; men should lie on left side with knees drawn up). Use a draw sheet to drape participant from waist to knees to maximize privacy but still allow necessary observation of pelvic floor muscle (PFM) contractions. The use of stirrups in women should be considered. * Before starting the internal examination, ask the patient to contract PFMs using cues such as "squeeze your pelvic muscle and try to pull in and up," "tighten up 1 like you are trying to not pass gas." * Observe externally the perineum (see illustration to the right) to assess if the patient is bearing down, using accessory muscles, or performing a correct contraction (perineal body, including vaginal introitus in women, and anus move inward [in men, the penis may lift]). * Muscle Assessment Vaginally: Insert one (or two) gloved, lubricated index fingers into the vagina to the depth of the proximal inter- phalangeal joint (see illustration to the right). * If vaginal stenosis or atrophy is present and/or patient expresses concern or discomfort/pain about undergoing examination, only insert one finger into the vagina, a. Muscle Location: Finger(s) are inserted into the vagina, finger pads down, in a posterior direction; eventually, they will encounter the edge of the levator ani (LA) (if proceeding more posteriorly, fingers will drop off the edge). Once at the edge, fingers should be retracted such that they rest on the muscle belly of the LA. Palpate the LA muscle laterally, at the four and eight o'clock position, just superior to the hymenal ring. Discomfort or tenderness to palpation should be noted. * Muscle Assessment Rectally: Inspect outside of anus to determine presence of hemorrhoids. Ask the patient to bear down or cough. a. Muscle Location: As the sphincter relaxes, gently insert index finger into the anal canal in a direction pointing toward the umbilicus. Note the resting sphincter tone of the anus. Normally, the muscles of the anal sphincter close snugly around the entire circumference of the examiner's finger. In the rectum, the distal external sphincter is felt just inside the anal canal. The PR portion of the LA muscle can be palpated about 2.5 to 4 centimeters from the anal verge. To assess the strength of the sphincter muscle, ask the patient to tighten his or her rectum around your finger. The examiner should feel a griping pulling in around entire circumference of finger. b. Insert the index finger farther into the rectum to examine as much of the rectal wall as possible. Palpate in sequence the right lateral surfaces, noting any induration, nodules, or irregularities. * Assessing Muscle Isolation: Ask the patient to contract PFMs around examiners finger(s) with as much muscle force as possible. Say to the patient: "I am going to count to 3, and when I say 3, I want you to contract your pelvic floor muscle for as long and as hard as you can." a. The following qualities of the muscle contraction should be assessed and noted: 1. Ability to produce force in the PFMs. 2. Ability to coordinate a PFM contraction. The patient should be able to contract PFMs without contraction of abdominal, hip adductors, and/or gluteal muscles. In addition, full muscle relaxation should follow a contraction. 3. Duration the participant can hold the contraction consistently. b. If no PFM activity is palpated, encourage the patient to contract again focusing on the PFMs, avoiding thigh and gluteal contractions. The examiner can palpate and gently (and if needed, repeatedly) press on the LA or rectal muscle to help the patient identify and activate this muscle. Source: [C] 2010 Diane K. Newman. Used with permission. Figure 4. Patient Education Tool: Biofeedback Treatment Biofeedback is a painless, effective treatment to help you identify and strengthen your pelvic floor muscles. Most men and women do not exercise these muscles the right way. Biofeedback will help you learn about your muscles and how to use them to prevent incontinence, bladder or bowel urgency, and frequency. Using biofeedback to retrain your pelvic muscles has been shown to help 8 out of 10 people and is the recommended "first-line" treatment for bladder and pelvic problems. What Is Biofeedback? Biofeedback uses a computer that records your muscle activity, the muscle contraction, relaxation, and strength. It produces computer-generated graphs that are displayed on a monitor. Biofeedback helps you find your pelvic muscles by showing changes when you squeeze or tighten the right muscle. Much like an athlete uses special equipment to train, you can use biofeedback equipment to reach a new level of strength in your pelvic muscles. Biofeedback can also use sound to help you identify the muscles you are to train. It teaches you not to tighten other muscle groups, such as your stomach muscles. How Is It Done? There are two different ways to provide the "feedback." One is to place two "skin patches" that have adhesive at your anus (the opening to your rectum). A second way is to insert a small sensor in your vagina (used in women) or your rectum (used in men or women). Either way, these pick up signals from your muscle and measure the muscle contraction and the relaxation. The sensors are connected to a computer that displays muscle changes on a monitor. You will immediately see when you are contracting the correct set of muscles and doing the exercise the right way. You will be able to follow your progress as your pelvic muscles gets stronger with each biofeedback session. How Long Is Each Biofeedback Visit? The biofeedback treatments are usually 20 to 30 minutes long, once or twice a month. How Many Biofeedback Treatment Visits Will I Need? To get the best results, you should have biofeedback visits over a six-month period and then follow-up treatments periodically, depending on your symptom improvement. But the frequency of biofeedback visits will depend on your muscle assessment at your first visit. In the beginning, you may need to come more frequently, maybe twice a week or more. For "homework" you will be given an "Exercise Prescription" to follow for exercising at home. You will also be asked to keep a Bladder Diary. Your progress will be discussed during your office visits, and the biofeedback will show you how your muscle is progressing. Source: [C] 2010 Diane K. Newman. Used with permission. This patient education tool may be photocopied.
Biofeedback Equipment And Parameters
Dr. Arnold Kegel developed the first biofeedback device, the perineometer, which was a pressure manometric sensor inserted into the vagina. One of its uses was to assist female patients with stress UI in identifying the PFM muscle and to visualize the feedback when contracting (Kegel, 1948). Since then, there have been no studies that have proposed the best equipment and/or technology to use when performing biofeedback for PFM dysfunction. In this author's experience, the system needs to be versatile because it should be operator- and patient-friendly. Optimal BF therapy includes visualization of both pelvic and abdominal muscle movement; thus, a two-channel system is available (Newman & Wein, 2013). A multichannel system allows for both pressure manometry and electromyography (EMG) channels. EMC is the measure of electrical activity of skeletal muscle--the PFM. Increased electrical activity is a result of more muscle activity; however, it is not a measure of force. Audio feedback can also be an attractive component of BF equipment.
For information to be accurate and helpful, instrumentation must be accurate and dynamic. In reference to PFM training, the instrument must be both sensitive and have little lag time in both displaying and recording information. Immediate, accurate "feedback" is the goal of the biofeedback instrument.
Cost and ease of use are also important considerations in biofeedback instrumentation. Higher cost does not always translate into better equipment. To date, there is no research, which has compared cost, ease of use, and accuracy of any BF system available for PFM dysfunction.
When looking into the instrument for use in delivering BF, careful consideration of the patient population is paramount. For example, if using this instrument with older adult patients, visual displays that can be seen by the aging eye are needed, or the instrument's auditory components should have a lower frequency sound that the aging ear can appreciate. Biofeedback displays that utilize games may be appropriate in children and younger adults.
Biofeedback parameters include measurement of resting tone, muscle strength (maximal and submaximal contractions), contractility, power, and endurance (ability to sustain a muscle contraction) (see Table 2). At least a five-second muscle relaxation period should be used between each contraction because easily fatigable muscles need a chance to recover, without permitting excessive rest periods for strong muscles. Measurement of EMG muscle activity is usually in microvolts, and measurement of manometric muscle activity is a measurement of pressure in millimeters of mercury. EMG provides information on the ability of the PFM to contract and manometry quantifies PFM strength. Electromyography, the electrical activity of a muscle, is a practical indicator of muscle activity and is defined as:
* The study of electrical potentials generated by the depolarization of muscle.
* A monitor of bioelectrical activity correlating to motor unit activity; it does not measure the muscle contractility itself, but the electrical correlate of the muscle contraction.
* An indicator of the physiological activity of the muscle.
The advantage of EMG over manometric pressure is that provided the machinery is of sufficient sophistication with adequate filtering, the EMG apparatus can accommodate the newer types of electrodes that are lightweight and designed to stay in place, hence allowing more functional positions during assessment and treatment.
Frequency of Sessions
Biofeedback sessions may be weekly, biweekly, and even monthly. Frequency of sessions should be individualized, and patients may need frequent sessions initially to aide in identification and isolation of PFMs. On the converse, less frequent sessions are helpful because changes in PFMs and lower urinary tract symptoms occur slowly. Improvement in pelvic support can be seen in one month, but significant changes occur after three to six months. Symptoms improve slowly, and tracking symptom improvement is essential to PFMT. Establishing realistic goals and expectations at the beginning of treatment can contribute to successful patient-centered outcomes.
During BF sessions, patients are taught quick muscle contractions (referred to as the "knack" or stress strategies) for use prior to the event that causes urine leakage (Miller, Ashton-Miller, & DeLancey, 1996, 1998). For example, if urine leakage occurs with a sneeze or cough, the patient contacts the PFM prior to or at the time of the event. For practice, the clinician will have the patient cough while viewing the BF screen and contract the PFM prior to and during the cough. Quick pelvic floor muscle contractions at the time of bladder urgency can suppress a strong urge, delay voiding and prevent an urge UI episode (Wyman et al., 2009).
Measuring PFM Response
There are several approaches for measuring PFM activity to ensure effective BF. First, PFMs as a group should be identified during a vaginal and/or rectal digital examination (see Figure 3, second illustration). It is helpful to guide the patient toward isolation of the PFM with minimal use of accessory muscle groups. In this author's experience, it is more effective that the clinician assist to confer success and support the patient rather than to focus solely on isolation of PFMs at any cost.
In specialty clinical practice, EMG measurement of gross neuromuscular function of the PFM is often performed by using electrodes that are placed on the skin surface (see Figure 3, second illustration) or sensors (probes) inserted in the vagina or rectum (see Figure 4, third illustration). Because the deep PFMs lie adjacent to the vaginal walls, a vagina sensor positioned against the lateral vaginal walls is a convenient means to record EMG activity in female patients (Keshwani & McLean, 2013). The longitudinal (lengthwise, not circular) detection electrodes on the sensor maintain the proper orientation to muscle fibers for highest accuracy. Manometry or pressure biofeedback can only be accomplished using intravaginal or intrarectal sensors. Patients often identify their PFMs with a sensor simply because the resistive device gives them something to contract against. All electrodes and sensors can be adapted for use with most commercially available instruments. Vaginal or rectal sensors are single use, and when in active therapy, patients use the same internal sensor at each session. An added benefit of internal sensors is that they can be used for both EMG and PFM electrical stimulation.
Figure 5 is the smallest, most comfortable female EMG sensor available, and features gold detection electrodes that provide consistently superior measurements and are also hypoallergenic. This sensor is inserted similar to a tampon and positioned above the urogenital diaphragm. It is able to measure muscle activity even when the patient is moving.
Evidence-Based Biofeedback Recommendations
The ICI Committee on Adult Conservative Treatment made evidence-based recommendations for PFMT and bladder training (BT), alone or in combination, (see Table 3), but the research is inconclusive to the improved efficacy of adding BF therapy as an adjunct method for PFMT for any dysfunction in the pelvic floor (Ayeleke, Hay-Smith, & Omar, 2013; Moore et al., 2013). A 2011 Cochrane review (Herderschee et al., 2011; Herderschee, Hay-Smith, Herbison, Roovers, & Heineman, 2013) on feedback or biofeedback to augment PFMT included 24 trials involving 1,583 women and concluded that women who received PFMT with BF were significantly more likely to report their UI was cured or improved compared to those who received PFMT alone. However, as with other research in this area, treatment groups differed on parameters other than BF, such as preparation of the clinician providing the therapy. A recent Cochrane review (Ayeleke et al., 2013) noted there was not enough evidence to say whether or not the addition of BF to PFMT in women with UI results in more benefits when compared to the same active treatment alone.
Since the 1980s, this author has used BF as an adjunct to PFMT in patients with PFM dysfunction. She conducted research in a community health center and home care setting (Baigis-Smith, Smith, Rose, & Kaschak, 1989; Newman, Lynch, Smith, & Cell, 1991; Rose, Baigis-Smith, Smith, & Newman, 1990). In a study conducted in a New Jersey public health center (Baigis-Smith et al., 1989), a portable EMG perineometer that provided feedback via the use of lights was used to provide biofeedback-assisted PFMT to 54 subjects, men and women, ages 60 to 86 years, with UI (Baigis-Smith et al., 1989). In addition to PFMT, subjects were also taught BT. The mean reduction in incontinence episodes was 78% from baseline, with 50% of subjects showing a 90% improvement. A second study (Rose et al., 1990) reported on 21 elderly homebound patients who were visited in their home and treated with PFM exercises and BF. Improvement in weekly incontinent episodes was 78% from baseline.
Use of Pelvic Floor Muscle Electrical Stimulation
Pelvic floor muscle electrical stimulation (PFMES) involves the application of low-grade electrical stimulation to the PFM. Electrical stimulation can activate inhibitory nerve fibers, causing reflex inhibition of the detrusor muscle, thereby preventing bladder overactivity (Newman & Wein, 2009). There is also an effect on the striated PFM, causing hypertrophy of the muscles by recruiting the PFM fast-twitch fibers. The delivery of the electric current to the PFM is via vaginal or rectal sensors, and the technique is often used in conjunction with biofeedback (Starr et al., 2013). Clinicians who specialize in pelvic floor dysfunction use PFMES as adjunct treatment to:
* Assist with identification and isolation of PFM.
* Increase PFM strength.
* Decrease unwanted or uninhibited detrusor muscle contractions.
* Assist with normalizing PFM relaxation.
This article is a short review of clinical application of biofeedback therapy in a pelvic floor muscle rehabilitation program. Clinicians providing this treatment should understand specifics about pelvic floor muscle anatomy, examination, measurement through EMG or manometry, and understand the parameters for providing appropriate feedback. Two case studies where biofeedback was integral to successful pelvic floor muscle rehabilitation are included (see Figure 6).
Figure 6. Case Studies Case Study #1 J.O. is a 56-year-old female diagnosed with multiple sclerosis eight years ago. She was referred to urology because of lower urinary tract symptoms, including incomplete bladder emptying and urinary tract infections. Patient's most bothersome lower urinary tract symptoms (LUTS) included urgency and frequency with incontinence. She reported poor bladder emptying, decreased force of stream, and a difficult time initiating voiding. She strains to void. Urodynamics studies indicated detrusor overactivity with incontinence, EMG activity indicated poor dyssynergia. Post-void residual was 450 mLs. Since then, she has been performing self-catheterization at least three times per day; catheterization volumes average 350 mLs. Catheterization has not changed her LUTS of urgency and frequency. PFM assessment indicated fair sensation, no discomfort, and levator ani palpation bilaterally, weak muscle contraction with length of fingers lifted and drawn in. Contraction duration was four seconds. Slight discomfort was noted during digital examination; it appeared as though muscle spasm was present. The patient purchased the vaginal sensor for use at weekly biofeedback (BF) sessions. Initial EMG BF session noted elevated muscle relaxation with generalized weakness. At this visit, BF was used solely to allow the patient to isolate muscle and to concentrate on relaxation. The patient was primarily prescribed a stepped strengthening exercise program with emphasis on muscle relaxation. Over a two-month period during the BF session, the patient worked to increase muscle strength and endurance. She continued on the prescribed muscle strength training and used muscle relaxation to aid voiding. By four months, the patient's urgency and voiding initiation improved. By five months, the patient was only self-catheterizing once a day because volumes had decreased to less than 200 mLs. She also stopped straining to void. EMG BF indicated very little muscle spasm, and muscle strength had increased by 40%. Case Study #2 S.A. is a 64-year-old female with a history of adenosquamous carcinoma of the uterus with invasion. She underwent abdominal hysterectomy with subsequent vaginal chemotherapy and pelvic radiation. The patient presented with both urinary and anal incontinence. The patient was told that cancer treatments resulted in PFM weakness causing her bowel and bladder symptoms. The patient also had urinary and bowel urgency and frequency. Her most bothersome symptoms were urgency; she lacked "control" and feared being in a situation where she would not be able to manage urinary and/or stool leakage. The patient was on a prescribed bowel regimen to keep stools soft, but she would have multiple daily bowel movements over a very short period of time. Endoscopy indicated that the patient had irritable bowel symptoms with alternating constipation and diarrhea, and the rectal scan revealed decreased sphincter tone. She kept daily records of bladder and bowel symptoms. The patient's oncologist recommended the patient undergo BF therapy, but she delayed seeking treatment because of ongoing cancer treatments and a generalized sense of hopelessness and embarrassment. Physical examination reviewed normal post-void residual and significant vaginal stenosis. Levator ani was palpated bilaterally with poor contraction of only one-second duration. Rectal sphincter tone was weak, and there was discomfort with the digital rectal examination. Because of the vaginal stenosis and rectal discomfort, the URway Intravaginal EMG Sensor[R] was used to provide BF. At the first session, the patient exhibited a very weak muscle with little sensation of contraction; the biofeedback EMG graph indicated a weak contraction of 2.0 to 2.5 microvolts. PFMES was attempted but was uncomfortable for the patient, so it was abandoned. For two months, the patient was seen weekly and received a 30-minute BF session. At the end of the two months, muscle sensation had improved, and strength had increased. At eight months, EMG testing indicated increased muscle strength (averaged 8.5 microvolts), normal relaxation (< 1 microvolt), and ability to sustain contract for eight to 10 seconds without accessory muscle contraction. The first symptoms to improve were urinary frequency and UI. The patient felt her rectal muscle becoming stronger, allowing her to use the muscle to suppress fecal urgency and prevent fecal leakage. There were ongoing instances where the patient reported being able to retain stool, such as when bending over, a cause of incontinence prior to starting the BF program. Stools also became more formed, aiding in control. The patient continues to use the intravaginal sensor as a training or resistive device for exercising at home.
Abrams, P., Khoury, S., & Grant, A. (2013). Evidence-based medicine--Overview of the main steps for developing and grading guideline recommendation. In P. Abrams, L. Cardozo, S. Knoury, & J. Wein (Eds.), Incontinence (5th ed., pp. 8-9). Arnhelm, The Netherlands: European Association of Urology Publications.
Ayeleke, R.O., Hay-Smith, E.J., & Omar, M.I. (2013). Pelvic floor muscle training added to another active treatment versus the same active treatment alone for urinary incontinence in women. Cochrane Database of Systematic Reviews, 11, CD010551.
Baigis-Smith, J., Smith, D., Rose, M., & Kaschak, D. (1989). Managing urinary Incontinence in community-residing elderly persons. The Gerontologist, 29(2), 229-233.
Corton, M.M. (2009) Anatomy of pelvic floor dysfunction. Obstetrics & Gynecology Clinics of North America, 36(3), 401-419.
Greer, J.A., Smith, A.L., & Arya, L.A. (2012). Pelvic floor muscle training for urgency urinary incontinence in women: A systematic review. International Urogynecology Journal, 23(6), 687-697.
Hay-Smith, J., Henderschee, R., Dumoulin, C., & Herbison, P. (2012). Comparisons of approaches to pelvic floor muscle training for urinary incontinence in women: An abridged Cochrane systematic review. European Journal of Physical and Rehabilitation Medicine, 48(4), 689-705.
Herderschee, R., Hay-Smith, E.J., Herbison, G.P., Roovers, J.P., & Heineman, M.J. (2011). Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women. Cochrane Database Systematic Reviews, 7, CD009252. doi:10.1002/14651858.CD009252
Herderschee, R., Hay-Smith, E.C., Herbison, G.P., Roovers, J.P., & Heineman, M.J. (2013). Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women: Shortened version of a Cochrane systematic review. Neurourology Urodynamics, 2(4), 325-329. doi:10.1002/nau.22329.
Heymen, S., Scarlett, Y., Jones, K., Ringel, Y., Drossman, D., & Whitehead, W.E. (2009). Randomized controlled trial shows biofeedback to be superior to pelvic floor exercises for fecal incontinence. Diseases of the Colon & Rectum, 52, 1730-1737.
Kegel, A. (1948). Progressive resistance exercise in the functional restoration of the perineal muscles. American Journal of Obstetrics and Gynecology, 56, 238-248.
Keshwani, N. & McLean, L. (2013). State of the art review: Intravaginal probes for recording electromyography from the pelvic floor muscles [Epub ahead of print]. Neurourology Urodynamics. doi:10.1002/nau.22529
Markland, A.D., Richter, H.E., Burgio, K.L., Wheeler, T.L. 2nd, Redden, D.T., & Goode, P.S. (2008). Outcomes of combination treatment of fecal incontinence in women. American Journal of Obstetrics and Gynecology, 199(6), 699.el-7.
Maserejian, N.N., Minassian, V.A., Chen, S., Hall, S.A., McKinlay, J.B., & Tennstedt, S.L. (2014). Treatment status and risk factors for incidence and persistence of urinary incontinence in women. International Urogynecology Journal, 25, 775-782.
McLean, L., Varette, K., Gentilcore-Saulnier, E., Harvey, M.A., Baker, K., & Sauerbrei, E. (2013). Pelvic floor muscle training in women with stress urinary incontinence causes hypertrophy of the urethral sphincters and reduces bladder neck mobility during coughing. Neurourology Urodynamics, 32(8), 1096-1102.
Miller, J., Ashton-Miller, J.A., & DeLancey, J.O.L. (1996). The knack: Use of precisely timed pelvic muscle exercise contraction can reduce leakage in SUI. Neurourology and Urodynamics, 15, 302-393.
Miller, J.M., Ashton-Miller, J.A., & DeLancey, J.O.L. (1998). A pelvic muscle contraction can reduce cough-related urine loss in selected women with mild stress urinary incontinence. Journal of the American Geriatrics Society, 46, 870-874.
Moore, K., Bradley, C., Burgio, B., Chambers, T., Hagen, S., Hunter, H., ... Williams, K. (2013). Adult conservative treatment. In P. Abrams, L. Cardozo, S. Khoury, & A. Wein (Eds.): Incontinence: Proceedings from the 5th International Consultation on Incontinence (pp. 1101-1228.). Plymouth, United Kingdom: Health Publications.
Newman, D.K., Lynch, K., Smith, D.A., & Cell, P. (1991). Restoring urinary continence. American Journal of Nursing, 91(1), 28-36.
Newman, D.K, & Wein, A.J. (2009). Managing and treating urinary incontinence (2nd ed., pp. 245-306). Baltimore: Health Professions Press.
Newman, D.K., & Wein, A.J. (2013). Office-based behavioral therapy for management of incontinence and other pelvic disorders. Urologic Clinics of North America, 40(4), 613-635.
Norton C., & Cody JD. (2012). Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. Cochrane Database Systematic Reviews, 7, CD002111. doi:10.10 02/14651858.CD002111.pub3
Rose, M.A., Baigis-Smith, J., Smith, D., & Newman, D. (1990). Behavioral management of urinary incontinence in homebound older adults. Home Healthcare Nurse, 6(5), 10-15.
Starr, J.A., Drobnis, E.Z., Lenger, S., Parrot, J., Barrier, B., & Foster, R. (2013) Outcomes of a comprehensive nonsurgical approach to pelvic floor rehabilitation for urinary symptoms, defecatory dysfunction, and pelvic pain. Female Pelvic Medicine and Reconstructive Surgery, 19(5), 260-265.
Wyman, J.F., Burgio, K.L., & Newman, D.K. (2009). Practical aspects of lifestyle modifications and behavioural interventions in the treatment of overactive bladder and urgency urinary incontinence. International Journal of Clinical Practice, 63(8), 1177-1191.
Newman, D.K. (2014), Pelvic floor muscle rehabilitation using biofeedback. Urologic Nursing, 34(4), 193-202. doi: 10.7257/1053-816X.2014.34.4.193
Diane K. Newman, DNP, ANP-BC, FAAN, BCB-PMD, is an Adjunct Professor of Urology in Surgery and Research Investigator Senior, Perelman School of Medicine, University of Pennsylvania' and Co-Director, Penn Center for Continence and Pelvic Health, Division of Urology, Penn Medicine, Philadelphia, PA.
Table 1. Muscles of the Pelvic Floor Origin Insertion Pelvic Floor Muscle Coccygeus Pelvic surface of Side of the coccyx and the ischial spine lower sacrum Levator ani (LA) Posterior surface Anococcygeal raphe of the body of the and coccyx pubis, arcus tendineus levator ani, ischial spine Layers of the Levator Ani Illiococcygeus Arcus tendineus Anococcygeal raphe (IC) levator ani, and and the coccyx the ischial spine (clinically called the levator plate) Pubococcygeus Posterior aspect Passes backward along (PC) of the superior the puborectalis muscle pubic ramis and inserts into the anococcygeal and the superior surface of the coccyx. Puborectalis Posterior aspect Proceeds backward (PR) of the body of the along the edge of the pubis genital hiatus in contact with the side of the vagina and loops around the rectum (anorectal junction) creating the anorectal angle below the coccyx Action Relevance Pelvic Floor Muscle Coccygeus Elevates the * Cases of pain associated with pelvic floor sitting, vaginal delivery, or chronic constipation due to prolonged, repetitive, or traumatic irritation and compression. Levator ani (LA) Elevates the * Serves as an inner-core pelvic floor, mid- muscle to provide lumbopelvic urethral vaginal stability, and it protects the vault, and anus pelvic girdle by resisting increases in intra-abdominal pressure. * Contracts during orgasm. * Ability to relax volitionally to assist normal urination and defecation. Layers of the Levator Ani Illiococcygeus Elevates the * Creates a supportive (IC) pelvic floor diaphragm posteriorly to resist elevated intra-abdominal pressures. Pubococcygeus Elevates the * Fibers create a band (often (PC) pelvic floor referred to as a hammock). * Provides essential support to the proximal bladder neck and urethra. Puborectalis Draws the distal * Pulls rectum toward during (PR) rectum forward contraction and assisting with and superiorly providing anal continence. Source: Adapted from Corton, 2009. Table 2. Measurement Parameters by Electromyography (EMG) or Manometry * Rest--The ability of the muscle to return to a resting state between each contraction. * Strength--Recorded as the peak maximum pressure (the maximal contraction) and the ability to sustain or hold the contraction. * Contractibility--The rate of the original rise of the muscle contraction. * Power-The ability of the muscle to "contract-relax" as quickly and strongly as possible, until the muscle fatigues; these are often called "quick flicks." * Endurance--The time that a sub-maximum muscle contraction can be maintained or repeated before a 50% or more reduction in power is detected (the muscle contraction is timed until the muscle fatigues). * Repetitions--The number of repetitions (up to 10) of the muscle contraction of equal force that can be achieved which indicate muscle coordination and function. * Fatigue--Failure to maintain the required or expected force of the PFM contraction for more than one or two times in succession. Source: Adapted from Newman & Wein, 2009. Table 3. ICI Grade of Recommendation Treatment Recommendations Grade PFMT Clinicians should provide the most intensive A program possible (in terms of exercise dose, health professional teaching, and supervision). Supervised programs taught by health professionals are better than self-directed programs; more health professional contact is better than less. Although studies are inconsistent, there does A not appear to be a clear benefit of adding clinic OR Home-based biofeedback to a PFMT B program. PFMT Supervised PFMT should be offered as first- A line conservative therapy to women with stress, urge, or mixed UI. PFMT in women PFMT is better than electrical stimulation as B with SUI first-line conservative therapy, particularly if PFMT is intensively supervised. PFMT is better than BT as first line B conservative therapy. PFMT in men Some pre-operative or immediate post- B post- operative instruction in PFMT for men prostatectomy undergoing radical prostatectomy may be helpful. The use of BF to assist PFMT is currently a B clinician/patient decision based on economics and preference. PFMT + BT in PFMT and BT are effective first line B women with UUI conservative therapy. For women with SUI or MUI, a combination of C PFMT/BT may be better than BT alone in the short-term. PFMT + BF Use of BF for the treatment of FI after other B behavioral and medical has been tried, if adequate relief has not been obtained. Notes: BF = biofeedback, BT = bladder training, PFMT = pelvic floor muscle train-ing, SUI = stress urinary incontinence, MUI = mixed urinary incontinence, FI = fecal incontinence, UI = urinary incontinence, UUI = urge urinary incontinence. A = Recommendation usually depends on consistent evidence from meta- analyses of RCTs or high quality individual RCTs. B = Recommendation usually depends on majority of evidence from RCTs or prospective cohort (case-controlled) studies. C = Recommendation usually depends on retrospective cohort (case- control) studies, case series, or low quality RCTs. Source: Adapted from Abrams, Khoury, & Grant, 2013; Moore et al., 2013
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|Title Annotation:||Advanced Clinical Practice|
|Author:||Newman, Diane K.|
|Date:||Jul 1, 2014|
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