Information for the Therapist: This chapter includes generalized
information on how to use the EMG perineometer sensor. See other
chapters for specific instructions for the care of the Sensors
and the operation of the Clinical, Personal, and Computerized
Perineometer™ EMG instruments.
Important: These instructions assume that you are
already familiar with the normal and conventional operation of
the EMG instrument with which it will be used. If not, you might
wish to obtain supervision from a person Certified by BCIA, the
Biofeedback Certification Institute of America (4301 Owens Street,
Wheat Ridge, CO 80033; telephone (303)-420-2902 for information
about certification).
Training and Certification in the techniques and principles of vaginal & rectal electromyography are provided by the non-profit Perineometer Research Institute, which offers monthly weekend seminars in the Philadelphia area and periodic training seminars throughout the United States and Europe. Write to the Institute at 242 Old Eagle School Road, Strafford, PA 19087, for the current training schedule.
The Electronic Perineometer™ brand vaginal myograph
may be used with any standard brand, quality EMG biofeedback instrument.
In selecting an instrument, the following considerations should
be weighed.
Multi-modal proportional feedback.
Instruments which provide both audible and visual feedback are
superior to single-mode devices, such as simple analogue (microvolt)
meters. The better instruments provide a variety of tones and
lights which may be selected to maximize patient responsiveness.
Discrete lights, especially in a bar-graph form (straight, diamond,
or circle) are generally considered best. Feedback should be derived
from an integrated EMG function, NOT raw EMG. For diagnostic and
training purposes, a "time-period" form of integration
is best. The simple "capacitor-smoothed" integrator
[such as found on the classic Grass brand polygraph, for example]
is calibrated in a "time-constant" but it does not mean
the same thing. Time period integration effectively provides a
measure of the "area under the curve". It is an arithmetic
average, which incorporates "amount" times "time",
averaged over a given time period. The 10-second average is the
average of the first second, plus the average of the second second,
plus the third, etc. Any instrument which provides less than this
is not really adequate. A surgeon would not normally operate with
a kitchen knife, even if it were a very good kitchen knife!
We recently encountered a physician who claimed to
be using EMG biofeedback for urinary sphincter training with only
modest results. Upon investigation, the "feedback" consisted
of having the patient watch, from some distance, a polygraph tracing
of raw EMG signals. The only quantification they used was "eyeballing"
the density of the pen tracing. Obviously from an experienced
biofeedback position, this did not constitute an adequate protocol
in any sense, and explains the poor results obtained.
Quantification. There
is no substitute for accurate digital representation of EMG data,
especially for diagnostic purposes. The ideal instrument should
have digital readout of both peak readings and integrated 10-second
holds. Without digital read out, there is too much opportunity
for the clinician to "see" what is expected, rather
than what is there. An ideal instrument would mechanically record
(print) the digital readout, or at least hold the numbers long
enough for manual recording.
Strip Chart. The ideal
instrument should also provide a mechanical paper-chart tracing
of EMG function, just like an EKG does. Visual inspection of the
strip-chart record (especially an integrated output) reveals important
information about muscle functioning. The so-called incremental
integrators [such as on the Grass Polygraph] are designed as an
alternative means for quantification, not for analysis of the
muscle activity patterns. They are an ancient (1940s) alternative
to modern digital computers, and deserve their proper resting
place. Please note that most laboratory-type polygraphs CANNOT
be connected to battery-operated EMG biofeedback instruments because
to do so would create patient electrical safety hazards, due to
different isolation techniques. Before attempting to interconnect
two different brands of equipment, always check with both manufacturers
for safety considerations. They may operate safely apart, but
not together.
The Personal and Clinical Perineometers were designed
by John D. Perry and William Farrall specifically to provide home
practice and office instruments with the features most needed
for pelvic muscle rehabilitation. Ten years of testing and refinement
have produced instruments which provide all the necessary features
without superfluous capabilities which would only add to the cost.
NOTE: Diagnostic and Therapeutic Techniques of vaginal
myography are described in detail in The G Spot and Other Recent
Discoveries About Human Sexuality, by Alice Kahn Ladas, Beverly
Whipple, and John Delbert Perry, published by Holt, Rinehart and
Winston, September, 1982 (hardcover) and by Dell, September, 1983
(paperback). See chapter 4, "The Importance of Healthy Pelvic
Muscles", for a discussion of the major issues and methods.
Since the work of California gynecologist Arnold
Kegel in the 1940s, it has been known that exercise may be used
to restore a weak or atrophied pubococcygeus (or "PC")
muscle for relief of urinary stress incontinence and other symptoms
of what Kegel called "genital relaxation". In 1947 Kegel
and his colleagues experimented with raw electromyographic biofeedback
of PC muscle activity, using electronic circuits developed during
the war. Unfortunately, they did not have our modern "voltage-controlled
oscillators" --- the sophisticated circuits that translate
raw EMG into rising and falling tones in today's biofeedback instruments,
so he resorted instead to a simple mechanical air-pressure gage
which he called the "Kegel Perineometer".
Physicians have differed during the ensuring years
about the viability of exercise in the treatment of PC problems.
Some, like Martin Weisberg, M.D., Professor of Ob-Gyn at Jefferson
Medical College in Philadelphia, have argued that exercise ought
always to be utilized first, and surgery resorted to only when
exercise fails to correct the problem. The majority, however,
have tended to overlook exercise entirely. The rationale is not
that exercise doesn't work, but that other methods are quicker,
or easier, or covered by third party payments. Because of the
limitations of the air-pressure perineometer, teaching patients
to do the exercises correctly was tedious and time-consuming.
The Electronic Perineometer™, used in conjunction
with contemporary, sophisticated EMG biofeedback instruments,
has restored exercise as a viable alternative to immediate surgery.
It is now possible to obtain accurate, precisely quantifiable
measures of PC muscle functioning and control. Using real-time
feedback, it is now possible to train PC control quickly and reliably.
This device has made it possible to apply the latest techniques
of muscle rehabilitation therapy to the pelvic area for the first
time.
In an important article, "Sexual Functions of
the Pubococcygeus Muscle", published in 1952, Kegel noted
what may be his most significant discovery: that improved PC functioning
(as a result of his exercise program) often resulted in dramatic
improvement in sexual response as well. A 1979 experimental study
by Graber and Kline-Graber gave support to the "Kegel Hypothesis"
that orgasmic capacity was directly related to PC strength. This
theory has been supported by the recent research of Perry &
Whipple; of Waletzky & Weiss, and of Wolf Eicher in Germany.
An examination of biofeedback theory (based in part
on the work of Gary E. Schwartz of Yale University) suggests that
there may be not one but two components which account for the
dramatic clinical improvement in sexual response which often accompanies
a disciplined program of Kegel Exercise. First, as Kegel believed,
mere physiological improvement in the health and tone of the PC
muscle itself may contribute a major part to increased sexual
pleasure. But in addition, the increased habitual mental awareness
of pelvic sensations and activity which are a necessary part of
the exercises may also contribute to sexual improvement.
The potential importance of both physiological and
mental factors in PC muscle retraining should be borne in mind
when undertaking vaginal myography. Practitioners would do well
to note the widespread utilization of autogenic, self-hypnotic,
and general relaxation techniques in the contemporary biofeedback
treatment of stress, for example. There exists a strong temptation,
perhaps owing to the psycho-social significance of the muscles
of the pelvic region, to depersonalize and mechanize its therapy.
Only after the client's goals have been ascertained,
a good therapeutic rapport established, and a comprehensive medical
and sexual history obtained, should the therapist actually begin
to use the techniques of vaginal myography.
NOTE: Obviously there
will be differences in the management of clients who present for
medical conditions, such as urinary stress incontinence, and those
who seek pelvic muscle training for sexual self-improvement. The
therapist should be alert to the possibility of changes in sexual
functioning among these "medical" patients, and the
possible "side effects" should be disclosed and discussed
just as in chemotherapy.
Motivation and Goals:
It is important to ascertain the client's motivation for diagnostic
evaluation and therapy. Unlike drug treatments, biofeedback therapy
does not "do" anything "to" the client; it
merely provides an educational opportunity far superior to that
found in nature; but it requires a strong personal commitment
to self-improvement and the learning process. Clients who appear
only at the urging of a dissatisfied partner may not be motivated
to do the exercise necessary for improvement in muscle functioning.
Therapeutic Rapport: Changes
in pubococcygeal muscle functioning and/or increased awareness
of pelvic activity, as brought about by biofeedback training,
invariably have far-reaching psychodynamic effects (especially
involving self-image) and interpersonal consequences (male partners
sometimes initially perceive the therapy as a threat). It is important,
therefore, that the therapist either ensure or establish a broad
therapeutic relationship with the client, and preferably with
the client's primary partner as well, before undertaking direct
muscle train ing. Male therapists must realize that female clients
are as sensitive about their muscle strength as males are about
penis size.
Medical and Sexual History: In
addition to standard medical history, the therapist may wish to
inquire about the client's awareness of pelvic muscle activity
at specific times. For example, severe cramps during menstruation
may be an indication of muscle tension. Is the client aware of
orgasmic contractions during sexual activity? What about contractions
during routine daytime activity (both males and females engage
in spontaneous PC muscle activity corresponding to mental sexual
arousal. It is often helpful to ask if the client already knows
about the "Kegel exercises". (Answers range from "What's
that?" to "(smile) I'm doing them now!") Information
about feedback which the client has received from partners during
sexual activity may be helpful. Success or failure at masturbation,
and during coitus, may provide additional diagnostic information.
NOTE: It is recommended that the Electronic Perineometer
always be referred to as a "sensor" or "vaginal
sensor", rather than as an electrode, since the latter term,
while technically correct, is potentially intimidating, while
the former emphasizes the essentially passive nature of the device.
It is recommended that detailed instructions concerning
the insertion, use, and removal of the sensor ALWAYS be demonstrated
in the office before the patient is allowed to practice at home.
This is important for two reasons: (1) to insure client's under
standing of the mechanical aspects of biofeedback training and
(2) to properly establish therapeutic goals. (See "Diagnostic
Evaluation" section, below.)
Patient compliance may be improved if a mini-lecture
on the pelvic musculature is included. We suggest that a dummy
myograph be placed over an anatomical drawing of the female pelvis
to illustrate sensor placement and its relationship to the pubococcygeus
muscle.
[Plate No. VI/8, "Ligamentous and Facial Support
of Pelvic Viscera", by Frank H. Netter, M.D., published in
Volume 2, Reproductive System, in The CIBA Collection of Medical
Illustrations, is an excellent drawing for this purpose. It is
reproduced with permission and included with this manual.] (Note
that Netter used the more inclusive term "levator ani"
to label the pubococcygeus muscle group, which appears in the
drawing as a "V" centered on the vagina.) A "dummy
vaginal myograph", available from Biotechnologies, Inc. may
be used with the drawing for demonstration purposes.
Therapeutic Location:
Even if a gynecological examining room is available, we recommend
that vaginal myography be conducted in a more comfortable, naturalistic
atmosphere. The ideal setting, a biofeedback training room, is
usually provided with a comfortable reclining chair in a "living
room" atmosphere illuminated by soft incandescent table lamps.
A wooden end-table should be used to hold the EMG instrument (if
needed), rather than "hospital" type carts. Ancillary
equipment, such as computers, should be kept out of view whenever
possible. (These recommendations are not trivial, as the major
therapeutic obstacle is usually transference of learning to "at
home" situations.)
Experienced therapists report that the myograph may
be conveniently sterilized in a standard "forceps jar",
available from medical and dental supply houses. (Plastic costs
about $8, stainless steel about $30.) The sensor should only be
left in the sterilizing liquid for the required time, and then
transferred to a comparable container of clean water for storage
before being presented to the client on a sterile disposable towel.
The thin connecting cable should be already attached to the 3-pin
plug on the sensor when the client receives it. [1996 note:
these instructions do NOT apply to the current "Single-User
Sensors", which cannot be sterilized.]
When convenient, the sensor and cable may be left
in the bathroom, to be inserted in private by the client. She/he
should be advised to empty her/his bladder before inserting the
sensor.
It is usually sufficient to suggest that the vaginal
insertion process is similar to insertion of a tampon, except
as noted: (1) If the labia and/or vaginal entrance is dry, the
tip of the myograph may be lubricated with saliva, water, or a
sterile lubricant such as "K-Y™ Jelly". Alternatively,
the dry tissue itself, instead of the sensor, may be lubricated
by the same means. In any case, only a minimum of lubricant should
be used. (2) Insertion should NOT be done over the toilet, lest
the sensor be dropped. (3) Finally, your instructions should emphasize
that the sensor is inserted only part-way into the vagina (or
rectum), with the cable and bulbous end remaining external. (Where
appropriate, you may wish to describe the sensor as resting in
the "orgasmic platform" as described by Masters and
Johnson.) Note that with rectal insertions, it is almost always
necessary to use a lubricant. However, if excessive lubricant
is used, the sensor may literally "pop out" while the
patient is trying to get dressed.
Note: Sterile lubricants
are available in convenient (and safe) foil packets containing
a single application. Ask your medical supply house.
The client should be instructed to insert the sensor
and let the cable come out under a dress or over the waistband
and return to the therapy room with the cable end in hand. (Walking
with the sensor in place helps to insure that it is comfortably
seated.)
Complaints about sensor comfort are relatively rare,
since the healthy vaginal barrel is capable of considerable distention.
Obviously the insertion process will receive special attention
when the presenting complaint is vaginismus. Many clients with
U.S.I. have large, gapping introituses and will have no trouble
inserting the sensor if moist. Some elderly clients with senile
vaginitis may prefer to start with the smaller "anal"
size sensor which is available from your supplier. Clients who
are unaccustomed to vaginal penetration may at first experience
some discomfort with any size sensor. Some therapists use the
anal sensor anally when treating U.S.I. in young girls with intact
hymens.
General Principles: It
appears that most of what is known about human muscles in general
is also true of the pelvic muscles in particular. For example,
a resting potential of 1 to 2 microvolts (RMS) is as reasonable
a goal for the pubococcygeus as for the frontalis.
The figures in this manual are given in "RMS",
or "root mean square" form, as provided by several popular
biofeedback instruments. (If your equipment uses "peak-to-peak"
averaging, be sure to convert these figures before comparing with
your own. One popular manufacturer recommends multiplying these
figures by 3.14 for comparison purposes.) Remember also that adjustable
"band-width" filters provided on some instruments can
dramatically effect the readings you obtain. It is essential that
the therapist understand these factors before rendering authoritative
diagnostic interpretations to clients! We generally recommend
the use of a "narrow" bandwidth of 100-200 Hz.
The first step in any EMG application is the establishment
of local baselines for your particular instruments and application
techniques. We recommend that you "practice" these procedures
with several peers of varying levels of PC muscle condition before
working with clients. You should seek out test subjects who can
candidly discuss their medical and sexual condition in order to
gain confidence and experience in interpreting the EMG data obtained.
The first step in diagnosis is to obtain a "resting"
or baseline measure. Initially, the PC may show a moderately high
EMG level for 20 or 30 seconds, due to the "stretch reflex"
which is triggered by the insertion process. Normally the EMG
level will drop to 2 or 3 microvolts within a minute or two, as
evidence that the client has begun to relax. An inability to relax
in a short time may be a function of anxiety growing out of the
diagnostic situation itself ("Situational Tension"),
or it may reflect a pathological condition ("Chronic Pelvic
Tension"). If resting EMG does not drop to a relaxed level,
that should be noted. If tension is severe, the client should
be instructed in general relaxation techniques before proceeding.
At this point the client should be asked to "do
a couple of Kegel exercises", which provides an opportunity
to (1) verify the integrity of the EMG circuit and (2) make an
initial estimate of the most appropriate measurement scale (range
switch) to use for evaluation.
Standard procedures for evaluating the quality of
electrode contact should be employed. If "raw EMG" sounds
are available, listen for 60 Hertz artifact indicating poor skin
contact. Normally, a digital "multimeter" (ohm-meter)
is used to check the resistance across all three electrode lead
combinations. All readings should be in the neighborhood of 10
to 20 Kohms. In any case, follow the same procedures as recommended
for surface electrodes.
There is no special reason to avoid therapy during
menstruation, but note that if the client has just removed a tampon,
the vaginal surface may be without natural vaginal lubrication
(which performs the same function as electrode cream or paste
does with surface electrodes). In this case, a few preliminary
contractions may restore electrode contact.
There are three basic diagnostic tests currently
recommended. At the present time, we suggest that data be recorded
for all three tests, but that the 10-second "hold" be
considered the best single-score summary.
Flicks: Flicks are a measure
of short contractile strength of the PC muscle. The client is
instructed to contract as strongly as possible, and the highest
momentary reading is recorded. Subtract the preceding resting
level for a "net flick"; repeat this six times for an
"average net flick" score. This is a measure of "phasic"
muscle strength.
10-Second Holds: As above,
except that the client is asked to "hold" the contraction
for a full ten seconds, and an average for the time period is
calculated. (This is provided automatically by the Cyborg Q-700
data processor with time-period integration and by certain computerized
systems. Obviously the exact method chosen will depend on the
features available on your EMG and its integration options.) This
is a compromise measure and is the one to be preferred if only
one test is used.
The "relax" and "contract" signal
lights on the "Clinical Perineometer" from Farrall Instruments,
Inc., provide cues for this ten-second test. Users of other equipment
may employ a stop watch or digital clock, but an audible beeper
set for 10 seconds is most convenient since it does not interfere
with visual monitoring of equipment and client.
Endurance Test: We have
adopted a standard rehabilitation test for muscle endurance, which
consists of the time, in seconds, that the client is able to hold
above 50% of initial strength. Ask the client to contract the
PC and "hold" it as long as she can. Note the initial
peak reading, divide that by two, and count the number of seconds
that elapse before the muscle output drops to that 50% level.
(In practice, it is seldom necessary to let the test run for more
than about 30 seconds. Most patients will achieve less than 20
or more than 30 seconds on this test.) This is a test of the "tonic"
muscle strength.
A sample "Electronic Perineometer Diagnostic
Evaluation" Data Sheet is included in this booklet, and may
be photocopied or adapted for clinical use without additional
permission. Numbers in square brackets [1] indicate sequence of
steps. The chart is laid out to facilitate calculation of averages.
Clinical Test for Control: In
addition to measures of phasic and tonic strength and endurance
(above), it is advisable to observe the degree of neuromuscular
control present. Technically this may be defined as the latency
between the "contract" signal and the onset of EMG response,
and between the "relax" signal and an appreciable drop
in EMG level.
When a strip chart recorder is available (as provided
on the "Clinical Perineometer",) one can observe the
latency directly in the steepness of transitions between contractions
and relaxations; a clear and decisive movement should be evident
in the tracings. (Precise quantitative norms have NOT been established,
however.)
When a light-bar or large analogue meter is available as a part of the biofeedback instrumentation, it is easy to obtain a clinical estimate of neurological control by playing "follow my finger". The therapist points to an arbitrary point on the scale and directs the client to contract or relax to bring the EMG level indicator to that point. Then move up and down the scale, and observe the client's ability to "follow" the moving finger. Persons with healthy muscles and good control can follow the finger as readily with their PC muscle as they could with a pencil held in the hand. Persons with poor control may not be able to synchronize their movements at all. Obviously clinical experience is a necessary prerequisite to effective utilization of this test.
ELECTRONIC PERINEOMETER
DIAGNOSTIC EVALUATION
Name:___________________________________ Date:______________________
I. Flicks. (Quick Strong Contractions)
Baseline Contracts Relaxs Postline
[1] ____ uV [4] _____ uV [5] _____ uV [16] _____ uV
[2] ____ uV [6] _____ uV [7] _____ uV [17] _____ uV
[3] ____ uV [8] _____ uV [9] _____ uV [18] _____ uV
[10]_____ uV [11]_____ uV
[12]_____ uV [13]_____ uV
SUMS: [14]_____ uV [15]_____ uV
_____ _____ _____ _____
/3=_____ /6= _____ /6= _____ /3= _____
_____ minus ->_____="Score"-->_____
---------------------------------------------------------------------
II. 10-Second Holds.
(Contractions Sustained for 10 seconds)
Baseline Contractions Relaxations Baseline
[1] ____ uV [4] _____ uV [5] _____ uV [16] _____ uV
[2] ____ uV [6] _____ uV [7] _____ uV [17] _____ uV
[3] ____ uV [8] _____ uV [9] _____ uV [18] _____ uV
[10]_____ uV [11]_____ uV
[12]_____ uV [13]_____ uV
[14]_____ uV [15]_____ uV
SUMS:
_____ _____ _____ _____
/3=_____ /6= _____ /6= _____ /3= _____
_____ minus _____="Score"--> _____
(ABSOLUTE Strength) (Resting) (NET Strength)
---------------------------------------------------------------------
III. Endurance Test.
Initial Peak: ______/2 = 50% level: ______.
Held for: _____ Seconds
----------------------------------------------------------------------
Therapist: ____________________
Comments/Notes:
(Record EMG switch settings used for this session):
Note that the [numbers] refer to the sequence in which the data is collected.
In evaluating the diagnostic summary of data careful
attention should be given to interpretation of both absolute and
net strength scores.
In the pelvis -- as throughout the body -- healthy
voluntary muscles exhibit three characteristics: (1) They should
contract on command; (2) They should relax when not contracted;
and (3) They should respond to commands. These logical alternatives
provide a basis for diagnostic interpretation of EMG findings.
Category 1: PC Muscle Weakness:
The most common PC problem is general lack of contractile strength.
The muscle responds to commands, but does so within a very limited
range. Perry and Whipple (1980) reported that their research subjects
(including patients and non-patients) obtained a ten-second "hold"
average of 8.77 microvolts RMS (i.e., "score" II on
the preceding page.) The range was from 0.2 microvolts RMS (for
a 72 year old woman with Parkinson's Disease and urinary incontinence)
to 45 microvolts RMS (a 23 year old woman).
Note: the "average" reading of 9 uV RMS should NOT be considered a goal, since the "average" woman has relatively weak PC muscles and will see a physician at some point in her life because of the problem. In general, 12 to 15 uV RMS should be considered minimally healthy. Women who already engage in the recommended prophylactic regime of Kegel exercises typically record 20 to 25 uV RMS for the 10-second average score.
Clients with urinary stress incontinence typically
register scores of only 2 to 4 microvolts RMS upon initial testing,
and EMG results appear to be related to the severity of the symptoms.
Such clients often also report a partial or total lack of orgasmic
contractions, or an inability to orgasm without substantial amounts
of sexual stimulation.
Differential Diagnosis of "Female Ejaculation":
Therapists should be aware of the research of Belzer, Perry &
Whipple, reported in the February 1981 issue of The Journal of
Sex Research, and described in some detail in Chapter 3 of The
G Spot, concerning the phenomenon of female ejaculation, which
is often confused with urinary incontinence. According to those
reports, some 10 to 40 percent of women "occasionally"
to "always" emit, at the moment of orgasm(s), a fluid
which is similar in chemical composition to the male ejaculate
(without sperm, of course) but usually thinner in consistency.
While it is presumably possible for women to urinate
during orgasm (the female urethral neck area typically contains
fewer of the cells which are believed responsible of the inhibition
of urination during sexual arousal in males), it is no longer
safe to assume so in many or even most cases. Objectively, "ejaculation"
appears to be correlated with PC muscles which are considerably
stronger than average, while "urination" appears
to be related to weak muscles. Subjectively, it is reported
that female ejaculation smells and tastes quite different from
urination. See The G Spot for further details.
Category 2: PC Muscle Tension: The
original Kegel Perineometer operated on the basis of physical
displacement, and was unable to differentiate a "small"
vagina from a "tight" one. Thanks to EMG instrumentation,
it is now possible to evaluate the relaxation level of pelvic
muscles (just like any other voluntary muscles). Clinical observations
suggest that the PC is subject to patterns of habitual tension,
especially under conditions of emotional stress, just like other
muscles. In general, pelvic tension often (but NOT always!) mirrors
general bodily tension; persons who are habitually tense throughout
register 3 to 5 µV RMS with the Electronic Perineometer,
while "normal" persons register 1 to 2 µV, and
persons adept at systematic relaxation techniques (such as T.M.,
Yoga, etc.) often register below 1 µV RMS.
But it is also true that the PC (like other muscles)
may be subject to idiosyncratic habitual tension which cannot
be ascertained by evaluation of the frontalis (forehead) muscle.
Just as some people develop patterns of neck or jaw tension, others
develop specific patterns of PC muscle tension.
A. Situational Pelvic Tension: Some
persons develop pelvic tension only in response to specific situations;
vaginismus (painful or impossible vaginal penetration during sexual
relations is the most obvious example). In an unpublished study,
Perry observed significant levels of tension during relevant fantasy
on the part of a patient suffering from genital herpes. The use
of behavior therapy techniques and mental imagery may prove useful
in the treatment of situational tension; obviously, the extent
to which the client is able to re-create the tension-producing
situation in the diagnostic environment will determine the validity
and usefulness of vaginal myography in such cases.
B. Chronic Pelvic Tension: Perry
and Whipple (1980) reported for the first time their observation
of chronic pelvic tension, which often masquerades as "low
back pain". While many complaints of back troubles are indubitably
related to spinal problems, it appears that a significant number
of symptoms may in fact reflect pelvic muscle tension. (The same
is true of some reports of abdominal pain.) In addition to "pain",
persons with tension levels of 5 to 10 microvolts RMS often complain
of a partial or total lack of feeling in the vagina, and may indicate
no awareness of PC muscle contractions during orgasm.
Frequently the apparent cause of pelvic tension is
a habit of infrequent urination, often resulting from a fear of
infection from public toilet facilities. Ironically, such persons
often suffer from frequent recurrent vaginal or urinary tract
infections which are resistant to chemotherapy. It is hypothesized
that habitual pelvic tension interferes with normal blood and
lymph circulation, and thus impedes the process of natural healing
and drug therapy as well.
When high levels of resting EMG are discovered, the
therapist is advised to investigate the occurrence of these symptoms.
Many persons mistakenly boast of their bladder capacity, as if
over-developed sphincteric control were a virtue.
Category 3: Neuromuscular Control:
In healthy persons, the PC muscle appears to be capable of the
same degree of conscious control as other skeletal muscles. We
expect a person to be able to raise and lower the arms, for example,
with a high degree of precision. In contrast, a wide range of
neurological control is evidenced in PC muscle evaluations. At
one extreme, some clients are oblivious to its existence or contractile
state. At the other extreme, reports of PC control approaching
conventional manual dexterity are not without foundation.
"Control", as applied to the human body,
has two components. First, it most obviously refers to the ability
to direct commands through neural pathways to specific muscles
to initiate contractions. Second, "control" requires
the ability to perceive that the command has been received and
the action has occurred. The process is described as a "positive
feedback system". In the case of the pelvic muscles, awareness
of pelvic conditions and contractions plays a significant role.
For example, some women are able to accurately describe the passage
of a single drop of menstrual blood through the vagina. On the
other hand, many women have been taught to avoid paying attention
to the pelvic region and its sensations, and lack that portion
of the ability to "control" their PC muscles.
The problem of evaluating control is somewhat complicated
by a factor which is probably best understood as a manifestation
of "state-dependent learning"; some clients manifest
significantly different patterns of neurological control in a
sexual situation. Perry and Whipple (1981) report a case in which
a woman was evaluated first in a gynecological examination room,
and shortly afterwards in her own home; the latter reading was
three times higher than the former, and may have reflected her
level of comfort there. On the other hand, some research subjects
who are justifiably satisfied with their sexual response patterns
have been incapable of complying with the 10-second "relaxation"
intervals specified in our standard diagnostic evaluation. When
they contracted their strong PC muscles, they could/would only
do so for several minutes at a time.
Dysmenorrhea (painful
menstrual cramping) is generally considered a "tension"
problem for which relaxation is prescribed (either through relaxant
medications, or painkillers which dull the awareness of the initial
pain, or as is increasingly common, masturbation as a means of
relaxation.) We prefer to consider it a "control" problem,
since preliminary research indicates that many women who suffer
from painful cramps are unaware that they can exert voluntary
control over them.
Consider the following psychological interpretation
-- which should be carefully distinguished from a "psychiatric"
one. Initially, there is pain associated with the monthly deterioration
of the uterine lining, triggered by hormonal changes. A natural
-- but counter-productive -- response to the initial pain is to
clench the muscles, which go into spasm and create further pain.
To avoid both initial and subsequent pain, sensory awareness is
"turned off" (both through the use of analgesics and
by the psychological process of "selective attention"),
resulting in a diminution of sensory feedback and concomitant
additional loss of muscular control. In such a situation, a person
would exhibit a lack of PC muscle control during cramps, which
is exactly what has been found in clinical practice.
It is NOT clear what proportion of dysmenorrhea cases
are best described by the above model, but it is certain that
at least some are. In those cases, prompt and permanent relief
has been obtained following a single 1-hour session of biofeedback-
assisted Kegel exercise training.
Diagnostically, clients suffering from dysmenorrhea
-- especially if evaluated during an attack -- will exhibit very
powerful contractions which are unrelated to conscious volition.
We have observed cases of a negative score for "10-second
holds", combined with very high (25-35µV) absolute EMG
levels; in other words, such clients actually contract their muscles
when they think they are relaxing them, and visa-versa.
When the Client Feels Threatened: Many
clients, having read The G Spot and having a basic understanding
of biofeedback, will be ready and enthusiastic about beginning
pelvic muscle training with vaginal myography. Others will be
more skeptical, not simply out of ignorance but because -- as
in any biofeedback situation -- acceptance of personal responsibility
for one's health is often a difficult barrier to overcome. It
is not unusual for patients to totally deny any awareness of their
responsibility for the rising and falling tones of the biofeedback
instrument. ("I'm not doing that!" "I don't know
why the indicator is moving!" are comments frequently made.)
When the patient is unable to accept responsibility,
the thoughtful therapist will seek to reduce the patient's anxiety
and at the same time begin to cultivate a sense of personal control
by switching, temporarily, to a non-threatening muscle. In such
cases, training should begin with a demonstration of the EMG instrument
applied to a neutral muscle, such as the forearm, using conventional
surface electrodes. When the patient observes that she/he can
control the biofeedback signal there, move on to the frontalis
(forehead). At this point, conventional relaxation training may
be given, to the patient's short and long term advantage. Only
when the patient is relatively relaxed and comfortable can the
insights of biofeedback training be utilized advantageously.
Why Biofeedback Works:
One way to understand the effectiveness of biofeedback training
is in an information processing model. In this sense, "knowledge"
is "power" to control one's own body. Body knowledge
can be seen as information, much like the "information"
on a TV screen. When the signal is weak, the picture is "snowy".
To improve the picture, it is necessary to improve the "signal-to-noise
ratio". There are two ways to do that: (1) increase the signal,
and (2) decrease the noise. In vaginal myography, as in biofeedback
in general, we usually attempt to do both!
First, we increase the
signal by providing direct, real-time feedback of information
about muscle activity. This same information is, of course, already
available through the various proprioceptive sensors in the muscle
fibers themselves, but many people lack confidence and/or experience
in interpreting these signals when they arrive in the brain. By
pairing the external, electronic signal with the internal ones,
we temporarily augment the signal (make it stronger) and at the
same time increase the patient's confidence in her own judgement
about recognizing and interpreting her internal cues.
Simultaneously, we encourage
relaxation of the mind and body in general, and of the pelvic
region in particular. By teaching the patient to "calm down",
we are seeking quite specifically to lower the mental and bodily
"noise" that interferes with recognition and interpretation
of biological feedback. (One function of using mental imagery
in conjunction with biofeedback training is that the process of
focusing on a specific image precludes think ing about other things;
i.e., it quiets the mind.) Lowering the "noise" level
improves the "signal-to-noise ratio" and, there fore,
increases the level of control the person has over her own body.
Self-Control As A Learning Process:
It is generally assumed that essential self-control must be learned,
and that once it is learned, it is "self-maintaining".
For example, the freedom from urinary urgency, or the enjoyment
of one's sexuality, is assumed to be inherently reinforcing and
therefore will continue, once the patient learns how to do it.
While this is generally true, it is well known that "secondary
gain" from common symptoms is a major stumbling block in
all biofeedback therapy. Some people get psychological benefits
from being ill, and many are afraid or unwilling to enjoy their
sexuality. When biofeedback therapy appears not to be working,
the therapist will consider such possibilities.
In general, biofeedback therapy for pelvic muscle
problems consists of the informal repetition of the same procedures
used in diagnosis (above), with clinical insight and interpretation.
The focus of training may be on increasing contractile strength,
but it will often be necessary to remind the patient to relax
between contractions, so "control" is always involved.
It may help to remember the Zen saying: "When you sit, sit;
and when you stand, stand."
The following suggestions are based on clinical experience,
but it should be noted that as yet no systematic research has
been done to establish empirically the most effective training
procedures*. We begin by attempting to isolate the PC muscle from
other nearby muscles (such as buttocks, abdomen, and thighs).
When the PC is isolated, it is possible to do the Kegel exercises
with a minimum of physical effort. Conversely, when many nearby
muscles are simultaneously contracted the exercises quickly be
come tiring and are frequently abandoned prematurely. (Moreover,
it is commonplace that, when many pelvic muscles are employed,
the PC itself is not contracting!) [* - Nine years later, this
is still true!]
Some patients find it easier to contract several
muscles and then "let go" of first one and then another,
leaving only that one muscle contracted which keeps the EMG biofeedback
reading high. Others prefer to experiment with a relaxed state,
contracting only that muscle which effects the EMG feedback signal.
Visual Imagery: Most patients
respond well to the use of visual imagery. Show a diagram (such
as Netter, Vol. II, Section VI, Plate 4, or The G Spot, page 89)
which depicts the "triple figure eight" which the external
sphincters form around the urethra, vagina, and rectum. Suggest
that each circle can be seen to get smaller when contracting.
One patient was having great difficulty increasing her contractile
strength. Finally, we discovered that she was image-ing the PC
muscle as being located at the depth of her (no longer present)
uterus -- some four inches away from its actual location. She
improved quickly after reeducation. It is worth recalling that
patients seldom "hear" anything in the "doctor's
office".
Another useful image:
have the patient reach down and pull on an imaginary tampon string,
imagining the sensations as the imaginary tampon meets resistance
from the contracted PC muscle. (One bioenergetics therapist managed
to triple her perineometer EMG score in just a few seconds using
this image.)
In difficult cases: It
is sometimes advantageous to employ a second EMG instrument with
standard surface electrodes on the offending extraneous muscle(s)
to train relaxation of them. Certain physical therapy EMGs with
"A minus B" dual-channel operation are especially useful
in this application. One can also employ "natural" biofeedback
to monitor extraneous muscles; a hand placed on the lower abdomen
will readily detect contractions there; gluteal contractions may
be observed in an elevation of the pelvis above the chair or bed.
Aductor (inner thigh) contractions may be observed by making certain
that the knees are kept slightly apart.
Many patients will insist that they can contract
best only in one or another special position. Often they are actually
wrong, and this can readily be demonstrated with the biofeedback
instrument. In any case, such superstitious behavior should be
discouraged, since it limits the natural realm of PC muscle exercise
to idiosyncratic conditions.
While isolation of the PC is generally considered
a first step in training, in the case of very weak muscles an
opposite strategy may be employed. Physical therapists recommended
the use of "overflow" (a standard physical therapy technique)
for the early stages of PC muscle training when there is very
little muscle output. The patient is instructed to press the knees
tightly together to augment the EMG signal, and exercise continues
in this manner until a consistent high reading is obtained. The
adductors (inner thigh muscles) are advocated for "overflow"
because in the second stage it is relatively easy to then instruct
the patient to discontinue their use, and compliance can be readily
observed by asking them to keep their knees slightly apart "from
now on".
There are no empirically established models for PC
muscle training. In our clinical experience, we usually spend
10 to 15 minutes reviewing the patient's at-home practice records,
10 minutes in formal diagnostic re-testing, and an additional
15 to 20 minutes in biofeedback training at each weekly session.
Some patients will tire quickly and need to rest (especially in
the early stages), while others will exercise constantly. The
office practice is explained as a training and progress checking
session, with the "real work" to be done with a "home
trainer" EMG instrument, at home on a daily basis between
weekly appointments.
Week-to-week improvement in measured PC muscle strength
will usually be a linear function of the amount of exercise which
has been done during the preceding week. It is not unusual for
weekly variations of 25% or more in EMG levels to be observed,
if there has been a significant change in the at-home exercise
pattern. To encourage regularity, a daily calendar/exercise check
list should be furnished to each patient to record the number
of formal exercises which were done each day.
Arnold Kegel originally advocated the use of some
300 contractive exercises daily as a therapeutic measure (and
100 a day forever as a prophylactic standard). Some therapists
have allocated this as thrice-daily sessions of 100 contraction
each. Others recommend more spaced practice: Elizabeth Noble recommends
50 sets of five 5-second contractions [Essential Exercises for
the Child-bearing Year, Houghton Mifflin, 1982, (Second edition);
Chapter 2 is highly recommended]. Massed practice may be easier
to document, but the spaced recommendation of Noble may be therapeutically
advantageous. Our laboratory studies have shown that "healthy"
persons habitually exercise their pelvic muscles throughout the
day, especially (but not exclusively) in response to sexual stimuli
and fantasy. One hypothesis about PC muscle weakness is that the
person has failed to develop this normal, healthy habit.
The therapeutic task, then is to make frequent PC
muscle contractions an automatic reflex. One way to do this is
through the well-known behavior modification technique of utilizing
commonly occurring "cues". We refer to this as the "spontaneous"
part of PC muscle exercise. Noble suggests PC contractions be
done at red traffic lights, during boring parties, every time
a commercial interrupts the TV program, anytime you have to wait,
or "any other time that you think of doing them" (p.
44).
This page is www/incontinet.com/articles/art_urin/HOPCHAP2.htm
Copyright 1996 by John D. Perry
Use your browser's back-arrow to return to the previous page
Click Here to return to our Home Page.