ELECTROMYOGRAPHY Urinary and Fecal Incontinence Introduction

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ELECTROMYOGRAPHY Urinary and Fecal Incontinence Introduction Powered By Docstoc
    Applications in Physical Therapy
                Urinary and Fecal
          The Use of Electromyographic
          Biofeedback for Training Pelvic
                Floor Musculature
                            Jacques Corcos, MD
                    Associate Professor, McGill University
                        Chief Department of Urology,

                          Sir Mortimer B. Davis
                 Jewish General Hospital, Montreal, Quebec

     Stephen Drew, Ph.D. Biofeedback Associates of Northern California
                             San Rafael, CA

                               Linda West, RN
                           University of Tennessee
                          G.I. Division, Memphis, IN

Incontinence is a major healthcare problem costing a conservative
estimate of $10.3 billion, annually, in the USA. Patients with this
problem often lead lives of quiet desperation and social isolation.
Incontinence is the second leading reason for nursing home placement
with approximately 50% of all residents being incontinent. While it is
estimated that the number of incontinent geriatric patients can be as
high as 80%(15), it is more difficult to estimate the incidence in
younger populations. Sandler(17) claims that only one out of twelve
incontinent patients actually report their symptoms to their doctors.
 One Danish study(6) conducted with a group of 45-year-old women found
 that 22% experienced stress incontinence. The average length of time that a
 woman is incontinent before seeking medical evaluation is 9 years. It was
 also noted that only three percent of these women sought medical
 attention for their problem.

 A persistent myth is that incontinence is a natural part of aging. In fact,
 fecal incontinence is prevalent even in children where approximately
 1.5% of 7 year olds are affected(18). The true reason for incontinence is
 seldom found. Many combined factors, other than age, including hormonal
 status, childbirth, previous surgery, muscular dysfunction, physical injury,
 medication, etc. are often responsible for the incontinence.

The three main forms of urinary incontinence are stress, urge and
overflow. Fifty to seventy percent is stress incontinence, which occurs
when the intra abdominal pressure is raised above urethral resistance.
This can happen while coughing, sneezing, bending, lifting a heavy object
or participating in athletic activities. Another 20-40% is urge
incontinence, which is the inability to inhibit urine leakage long enough
to reach the toilet when one senses the urge to void. Only 5-10% is
overflow incontinence, which occurs when the bladder cannot empty
completely because of obstructions or loss of bladder muscle strength,
and, thus, becomes over distended. It leads to frequent, and sometimes
nearly constant, urine loss, and usually requires medical management.

Urge and overflow incontinence are sometimes improved by
pharmacologic manipulations. Anticholinergic drugs are usually potent
inhibitors of contractions, and blocker agents can help when overflow
incontinence is secondary to a bladder neck obstruction such as prostate

Very few controlled studies have shown patient improvement of stress
incontinence using medication, estrogens, stimulator agents, etc.
Behavioral modification as a treatment modality for urinary
incontinence has been the focus of clinical attention only recently in
North America(1), although European doctors have used these
techniques for many years with a very high success rate.

The pelvic floor muscles are made up of the Levator Ani group and
include the pubococcygeus, puborectalis and the ileococcygeus. The
external sphincter of the urethra, as well as the anal sphincter are in
continuity with these muscles and both receive pudendal innervation.
Biofeedback, in conjunction with muscle contraction exercises, can
help strengthen the muscles needed to maintain bladder continence.

In a good review of incontinence(20), Tries states that the power of
biofeedback lies in it's capacity to shape patients to develop a greater
             sense of control and mastery of bladder and bowel function, thus
             reducing their fear, anxiety, and. A recent article in JAMA has gained
             significant publicity and increased public awareness of this type of

             A recent report from the U.S. Department of Health and Human
             Services, Agency for Health Care Policy and Research(23) on urinary
             incontinence, recommends that behavioral procedures, such as
             biofeedback, be attempted before consideration of surgical or other
             invasive techniques. The financial benefits of biofeedback were
             emphasized in 1984 by Rodin of the U.S. Public Health Service(16),
             who stated that if biofeedback techniques were used to treat
             incontinence in the elderly, as much as $13 billion dollars a year could
             be saved.

                     Assessment of Incontinent Patients
             Prior to being admitted to the biofeedback program, patients must be
             evaluated by a urologist, or other physician with expertise in this field.
             Some forms of incontinence, even genuine stress incontinence, could
             be secondary to a general disease (multiple sclerosis, diabetes, etc.) or to
             a local specific disease (carcinoma in-situ, interstitial cystitis,
             tuberculosis, etc.) for which biofeedback treatment may not be
             appropriate. However, in those cases, although biofeedback may not
             ameliorate the underlying condition, it may improve the incontinence.

            A daily bladder or bowel diary should be kept for at least 2 weeks prior
            to beginning a behavioral program. This should include the number of
            incontinent accidents, activity associated with the accidents and times of
            regular voiding and fluid intake. The evaluation will include a review of
            the patient's medical history, a vaginal and/or rectal examination,
            assessing bladder and urethral prolapse, rectal prolapse, muscle strength
            and ability of the patient to control his or her pelvic muscles. Usually,
            only urine analysis and culture are required, although, depending on
            history and physical examination findings, urodynamic testing,
            cystometrogram, abdominal leak point pressure, and/or bladder leak
            point pressure, x-rays and cystoscopy could be useful.                                                    5/27/98
Electromyography                                                                      Page 4 of 10

                                                  Reference '
                                                  Wire with            Disposable


                                        Figure 1. Training Exercises

          During the pre-treatment visit, the healthcare professional will provide
          educational information and explain the use of the equipment, including
          the sensor and its placement. Some patients express concern about
          adequate sterilization of vaginal and rectal sensors. Single user sensors
          may help reduce these concerns. If "T" shaped sensors (figure 1) are
          used, the patient need not undress, and, if able, they should be allowed
          to insert the sensor themselves, taking care that the large end remains
          outside of the vagina or rectum. If a rectal sensor is used in elderly or
          young children, some clinicians recommend that only someone with the
          appropriate training and licensure perform a digital exam to rule out
          obstructions, although the sensors do not very far into the rectum.Then,
          holding the sensor (which has a dab of surgical gel on the tip) in one
          hand, insert it while using a finger from the other hand to distend the
          anal opening. Gently push the sensor into the orifice, until all but the
          transversal end is inserted.

          If surface EMG electrodes(9-10) are to be used, however, partial
          undressing will be required. These electrodes are particularly useful for
          the pediatric population and have been shown to have a recording
          ability comparable with needle electrodes(9-10). The two active
          electrodes should be placed directly adjacent to the anus and the ground
          lead placed anywhere nearby (figure 2).
Electromyography                                                                        Page 5 of 10

                              Figure 2. Peri-anal placement of surface EMG electrodes

           Many                                                          clinicians
           find it                                                       valuable to
           assess and
           voluntary contractions. A suggested protocol follows:
          The patient, fully clothed, is seated in a recliner. The sensor is then
          connected to the EMG instrumentation. Using one of these instruments,
          baseline information is gathered for the resting EMG levels of the
          pelvic floor muscles. The resting EMG levels should be acquired over a
          1-3 minute interval (typically under 2 microVolts rms). The patient is
          then asked to tighten the pelvic muscles. Some clinicians suggest
          visualizing trying to stop a stream of urine while voiding, and to hold
          the contraction for 10 seconds (typically 10-20 microVolts in controls).
          A period of ten seconds of relaxation follows each voluntary
          contraction. It is important that the pelvic muscles are isolated and that
          the accessory muscles of the legs, abdomen and buttocks are not
          contracted. The clinician can generally observe this, but a second
          channel of EMG can be utilized to monitor undesirable activity from the
          abdominal region. The clinician should have the patient voluntarily
          contract/relax the pelvic muscles four to six times. These voluntary
          contractions should be observed for maximal amplitude, the average
          amplitude of the ten seconds, recruitment and fatigue. The resting levels
          should be observed for any spasms, as well as the time interval to go
          from relaxation to the maximal amplitude of the voluntary contraction
          and the time interval to return to the resting level. These measures
          called "latency" are typically 0.5 seconds for contraction and 1.0
          seconds for relaxation(14). If you are using a computerized program,
          you can set the display time on the single polygraph screen to a 2
          minute screen, after which you can save the data or copy the screen to a

                Biofeedback Technique for Pelvic Muscle
          The biofeedback approach for treating urinary incontinence was
          pioneered by Arnold Kegel in the 1940's. Muscle contraction exercises
          performed without EMG assistance can lead to contractions of other
Electromyography                                                                      Page 6 of 10

           muscles, such as the abdominals, buttocks and thighs, thus leading to
           fatigue and overpressure on the bladder. Several researchers have
           reported that EMG monitoring of the pelvic floor musculature through
           surface electrodes yielded muscle activity that correlated highly with
           fine wire needle electrodes inserted directly into the pelvic muscles(4-
           11). Surface EMG has also been demonstrated to be a highly effective
           treatment procedure(3,7,12,19). Home training with biofeedback has
           been demonstrated to provide significant enhancements of
           improvement in symptom reduction and elimination of urinary
           incontinence when compared with Kegel exercises alone, or in
           conjunction with a resistive device(13).

           Through trial and error learning, EMG biofeedback permits one to
           isolate only the pelvic muscles. If using a dual channel instrument,
           such as the MyoTrac 2(TM) EMG system or two MyoTrac(TM) units
           (both from Thought Technology Ltd.), one sensor can be placed on the
           abdominal muscles, halfway between the umbilicus and the pubis, to
           help the patient avoid abdominal contractions during pelvic muscle




                    Base flick             Rest-Hold                   Endurance

                    Figure 3. Sample EMG line graph trace

          There are several methods for training the pelvic floor musculature:

             • Muscle strengthening is done with maximal contractions which
               are held for 5-10 seconds at a time, with 10 second rest periods in
               between. These are repeated several times, until the contraction
               begins to show fatigue or when the patient begins to compensate
               with accessory musculature.
             • Endurance training is done with submaximal contactions held
               for increasingly longer periods of time. For example, a 50%
               contraction held for 30 seconds can be held longer at each
             • Speed of recruitment is practiced with several repetitive
               contractions (flicks) in a short time frame, for example, 10
               successive contractions performed within ten seconds.
             • A progressive contraction can also be done, asking the patient to
               contract and relax gradually. The total biofeedback time is
               approximately 15 minutes, the time spent on each type of
           training depending on the patient's problem and response.
 A review of the record-keeping data combined with a biofeedback
 session, is usually suggested every 7-10 days with the healthcare
 professional. The patient is asked to practice at home every day with
 two or three EMG feedback sessions, 5 to 10 additional non-
 instrumented muscle contraction exercises are also given. These should
 consist of 3 sets of contraction and relaxation exercises per session to
 begin generalization. During subsequent weeks, these exercises should
 be practiced with an increasing number of repetitions and effort.

 Several choices of monitoring instruments are available, single or dual
 portable EMG systems which provide audio and/or visual feedback are
 ideal for home training. A more sophisticated computerized data
 acquisition system is recommended for clinical assessment.

            Pelvic Floor Training with MyoTrac(TM)
    •     Set the MyoTrac(TM) scale at Xl and turn the threshold dial to
          .5 microvolts.
    •     Ask the patient to tense the pelvic floor musculature maximally
          and keep the contraction.
    •     Turn the threshold dial counterclockwise until the first red LED
          to the right of the yellow "threshold" LED is the one that is lit.
          Note the setting on the threshold dial.
    •     Ask the patient to perform a series of 10 second contractions
          which produce activity exceeding the yellow LED. If preferred,
          turn the tone on fully, so audible feedback will accompany any
          signal strength exceeding the threshold. Allow approximately 10
          second rest periods between each attempt. If the first red LED is
          significantly exceeded, re-set the threshold control to a higher
          level in order to enhance strengthening.
   •    Instruct the patient to be aware of muscle activity in the
        abdominal, buttocks and thigh regions, and to experiment with
        relaxing those areas while increasing the EMG readings. If you
        suspect that these muscles are being activated significantly, you
        may wish to place an additional sensor connected to another
        MyoTrac(TM) unit (or use a dual channel system) to demonstrate
        the necessity to maintain low muscle activity in surrounding
        musculature while performing the exercises. This is useful,
        especially during initial sessions.
   •    Once you are confident that the patient understands the electrode
        attachment and instrument setting procedure, you can proceed
        with home training instructions.

If working with a child or infirmed elderly patient, the assistance of a
parent or attendant may be helpful. Clear instructions as to the
frequency of practice and maintenance of the equipment should be
 A continuation of the daily records should be kept, these should include
 episodes of incontinence, degree of activity during episode as well as
 occasions of toileting without accident. It is imperative that the patient
 continue the muscle contraction exercises, even with the resolution of

 Incontinence is an extremely prevalent disorder. Biofeedback has had a
 great impact upon incontinence, due to its ease of use, low cost and very
 high success rate. EMG biofeedback can be used successfully, at home,
 by most patients. Although treatment time varies, in most
 people, continence can generally be restored in 4-8 weeks for both
 fecal and urinary incontinence, using the techniques described in this
 protocol, which combine clinical assessment and training with EMG

1. Bo, Kari, et al: Pelvic Floor Muscle Exercise for Treatment of
 Femele Stress Urinary     Incontinence. Neurology and Urodynamics
 9:471-477, 1990.

2. Burns, Patricia, et al: Treaturent of stress incontinence with pelvic
 floor exercises and biofeedback. J.A.G.S. 38: 341-344, 1990.

3. Drew., S.: A Short-TermBiofeedback Strategy for Treating
 Bladder Incontinence in Outpatient Females. Paper presented at
 the Biofeedbeck Society of California, Berkeley, CA. 1990.

4. Doyle, R.B., O'Donnell, P.D., Souheaver, G.T.: Biofeedback
 Training for Urinary       Incontinence in the Elderly. Abstract. Dept
 of Psych, Little Rock V.A. Med Ctr, Little    Rak, AR , 1987
5. Ferguson, Karen, L., et al: Stress urinary incontinence: Effect of
 pelvic muscle   exercises. Obst. & Gyn, Vol.75, No. 4, 671-675,
 April 1990.

6. Hording, V., Pedersen. K., & Sidenius, K.: Urinary incontinence
in 45 year old women.     Scandinavian Journal of Urology
Nephrology 20: 183-186, 1986.

7. Libo, L.M., Arnold, G.E., Woodside, J.R., & Borden, T.A.: EMG
biofeedback for     functional bladder-sphincter dyssynergia: a case
study. Biofeedback end Self     Regulation 8: 234-253, 1983.

8. Maeglia, James, P. et al: Post prostatectomy urinary incontinence:
Response to behavioral training. Jour of Urology, Vol. 144,

  674-675, Sept. 1990.
 9. Maizels, M., Firlit, C.F.: Pediatric urodynamics: a clinical
 comparison of surface versus needle pelvic floor/ external sphincter
 electromyography. Journal of Urology 122:518-522, 1979.

  10. Maizels, M., Kaplan, W.E., Lowell, R.,King, L.R., & Firlit, C.F.:
 The vesical sphincter electromyogram in children with normal
 and abnormal voiding patterns. Journal of Urology 129: 92-95,

 11. Nygaard, Ingrig, et al:Exercise and incontinence. Obst. &
 Gyn., Vol. 75, No. 5, 848-851 May 1990.

 12. O'Donnell, P., Doyle, R., & Beck, C.: Biofeedback therapy for
 urinary incontinence in older inpatient men. Urinary Incontittence
 in Adults (NIH Consensus Development) Washington, DC:
 National Institutes of Health, 1988.

 13. Petry, John D., Hullett, Leslie T.: The hole of home trainers
 in Kegel's Exercise Program for the treatment of incontinence.
 Ostomy/Wound Management 30: 51, Sept-Oct, 1990.

14. Perry, John D.: The Perry Protocol for Treatment of Incontinence.
Biotechnologies Inc., 1990.

15. Portnoi, V.A.: Urinary incontinence in the elderly. Am.
Fam. Physician 23: I51-154, 1981.

16. Rodin, J.: Interview with Faye Abdellah. American
Psychologist 39: 67-70, 1984.

17. Sandler, M.: Incontittence, urinary leakage - a common and
treatable condition. Daly City: Krames Communication.

 18. Schaefer C.E.: Childhood Encopresis and Enuresis, Causes
and Thaapy. New York, Van Nostrand Rheinhold, 1979.

19. Sugar, E.: Bladder control through biofeedback. American Journal
of Nursing : 1152-1154, 1983.

20. Tries, Jeanette: Kegel exercises enhanced by biofeedback. Jour
of Enterosomal Ther 17, 2:67- 76, 1990.

21. Susset, Jacques, G., et al: Biofeedback therapy for female
incontinence due to low urethral resistance. Jour. of Urology, Vol.
145, 1205-1208, June 1990.

22. Whitehead, W.E., Parker, L., Basmajian, L., Morrill-Corbin. D.,
Middaugh, S., Garwood, M., Cataldo, M., Freeman, J.: Treatment
of fecal incontinence in childrenm with spina bifida: comparison of
biofeedback and behavior modification. Arch Phys        Med Rehab
              67:21 8-24, 1986.
              23. Urinary Incontinence in Adults: Clinical Practice Guideline.
              AHCPR Pub. No. 92-       0038, Rockville, MD: Agency for Health
              Care Policy and Research, U.S Dept. of Health and Human
              Services, Mar 1992.

                            Copyright, 1997 The Biofeedback Foundation of Europe
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