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Pelvic floor muscle rehabilitation using biofeedback.

Pelvic floor muscle exercises have been recommended for urinary incontinence since first described by obstetrician gynecologist Dr. Arnold Kegel more than six decades ago. These exercises are performed to strengthen pelvic floor muscles, provide urethral support to prevent urine leakage, and suppress urgency. In clinical urology practice, expert clinicians also teach patients how to relax the muscle to improve bladder emptying and relieve pelvic pain caused by muscle spasm. When treating lower urinary tract symptoms, an exercise training program combined with biofeedback therapy has been recommended as first-line treatment. This article provides clinical application of pelvic floor muscle rehabilitation using biofeedback as a technique to enhance pelvic floor muscle training.

Key Words: Pelvic floor muscle training, biofeedback therapy, electromyogram, vaginal and rectal sensors, pelvic floor muscle electrical stimulation.

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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 Therapy

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.

Summary

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.


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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.
Publication:Urologic Nursing
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Date:Jul 1, 2014
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