With respect to the application of surface electromyography to pelvic floor muscles in the treatment of vulvovaginal pain, confusion reigns supreme amongst professionals as much as amongst patients. I often hear comments from professionals which clearly indicate that they lump all muscle measurement and treatment together. They confuse manometry (intravaginal pressure readings) and electromyography. They mistake electrical stimulation for biofeedback. They refer to physical therapy and biofeedback as if they are synonymous. They refer to vulvodynia/vestibulitis as if it is vaginismus (a psychological condition leading to circumvaginal muscles closing off the vaginal opening with attempted penetration). They refer to surface electromyography as if it is fine wire electromyography (a very painful measurement of individual muscle fibers by needle insertion of fine wire directly into the muscle). They mistake biofeedback as a psychological rather than a physical intervention (because biofeedback has its historical roots in the field of psychology) reinforcing inappropriate views held by many that all vulvovaginal pain disorders are essentially psychological. They use the term biofeedback and physical therapy as if they are the same interventions (which they emphatically are NOT). Is it any wonder that patients are confused when the professionals making the referrals hold so many misconceptions about this therapeutic intervention!

Surface Electromyographic Assisted pelvic floor muscle rehabilitation (Biofeedback) treatment of vulvovaginal pain is a very specific treatment. It involves the use of very specific instruments, software, home training devices, daily exercise protocols and muscle monitoring, specified schedules of office electromyographic evaluations as the basis for determining appropriate at home exercise variables (e.g. number of repetitions, contract duration, relax duration, contract onset/offset times, stability training, spectral frequency training, to mention a few) . You will find many practitioners who do not conduct treatment in line with any of the above parameters but claim to be conducting biofeedback. This may be a valid claim, they may well be conducting biofeedback. What they are NOT conducting is the GLAZER PROTOCOL.

So what is so important about which protocol is used?   Well, it is pretty simple actually. With respect to pelvic floor muscle rehabilitation in the tretment of vulvovaginal pain disorders, ONLY the GLAZER PROTOCOL has been shown to be EFFECTIVE by medical research standards (those standards accepted by the medical community and used by insurance companies to determine reimbursement). This standard involves the collection and analysis of data relating to the effectiveness of the treatment and the publication of this data in a “peer reviewed” medical journal. Other treatments may be effective but they have NOT demonstrated their effectiveness by this standard. BIOFEEDBACK for vulvovaginal pain remains a PATIENT BEWARE market. I urge you to evaluate your practitioners carefully. DO NOT accept verbal claims of treatment outcome. Neither patient nor practitioner beliefs or unsubstantiated claims about effectiveness are an acceptable standard. Ask your practitioner to see their documented sEMG and patient symptom reports and satisfaction data. If they cannot demonstrate that either 1. They are conducting the GLAZER PROTOCOL in which they have been adequately trained or 2. That they are conducting an alternate treatment protocol which has been demonstrated to be effective, then you have no basis to expect a positive treatment outcome.

Listed below are some questions that you can ask a potential therapist to screen for a promising one, or to review your past therapy and find out if you've really been there, done that. You should not hesitate to ask your therapist these questions, and if you are not satisfied, go somewhere else and try again. After each question we've listed some of the factors which should be weighed in evaluating the professional's answer.

• Will you personally be doing the biofeedback training, or do you have a technician, nurse or aide that does the actual work?

Because biofeedback is labor intensive, hardly any physicians actually do the biofeedback training themselves. If you are seeing a surgeon, he/she is probably trying to decide if you are a good candidate for an operation. Most of the other questions should be asked of the person who will actually be training you.

• How many times have you treated patients like me?

It is OK to work with beginners, everyone has to start somewhere --- IF they are properly supervised and trained.

• What specialized training did you receive to do this work?

Each profession (biofeedback, nursing, physical therapy) has several 2 to 5 days seminars every year on learning how to do pelvic muscle rehabilitation with biofeedback; at least one such Workshop would be minimal. Hearing a paper or presentation at the annual convention would not usually be considered enough training.

• Are you Certified in Biofeedback by the "Biofeedback Certification Institute of America (BCIA)"?

This will be hard to find, but represents a very high standard of preparation - in general biofeedback. If not they, are they supervised by someone who is certified?

• Are you a member of a ISSVD (physicians) or Women's Health section (physical therapists)?

The ISSVD, the International Society for the Study of Vulvovaginal Disease, and The Women's Health Section of the American Physical Therapy Association are both excellent sources of professional support and continuing education.

• What is the typical outcome for your patients using EMG biofeedback for vulvodynia?

It depends on the overall health of the typical patient in this clinic. In out-patient clinics where most patients are in otherwise good to excellent health, it should be a cure rate in the 50 percent range, and overall symptom reduction rate in the 85% range.

• What is the expected outcome in my case?

You will have to allow for your own physical condition in deciding what you consider a worthy answer here. Patient symptoms are extremely variable and satisfactory outcomes will be different for different patients.

• How long do you estimate the treatment will take?

In general, 9 months of diligent daily practice should get most otherwise healthy patients positive results. If your therapist doesn't have this skill, you might want to shop around. (By the way, it is considered good practice to over-train your muscles [beyond merely a single pain free week or even month] to prevent relapses.)

• How often will I get to use an EMG biofeedback instrument in my training?

There are two popular protocols, both based on the difficulty sometimes experienced in getting insurance coverage for take-home trainers. If a physician is doing the billing, the rental of a "home trainer" for daily biofeedback practice is sometimes absorbed into the weekly office visit charge. Physical Therapists can't do that, but they can let you practice in the PT clinic every day or every other day, and bill separately for "exercise". All of Dr. Arnold Kegel's patients had a home biofeedback device to practice with three times daily. The only published study of The Role of Home Trainers in Kegel Exercise Training is available for reading on Incontinet.com.

• Do you have vulvodynia treatment software running on a specialized biofeedback computer?

The use of general-purpose "relaxation"-type biofeedback software is not acceptable. There are several major companies that have developed software specific to evaluating and exercising the rather unique "pelvic muscles"; these programs also produce printed reports of your muscle condition to document your progress to the insurance company. If you want LESS than the best treatment available, well, it's your body!

• Do you use special insertable vaginal EMG sensors, or just surface "patch" electrodes?

All of the major vulvodynia systems are designed to use insertable sensors, because they all give much more valid and reliable indications of pelvic muscle activity than external surface electrodes. All American-made sensors with longitudinal (as opposed to circular) electrodes are licensed under the Perry patents. Longitudinal electrodes have been shown to correlate highly with "inserted needle electrodes", but without the risks or pain.

What's a "GOOD SCORE"?

We have not attempted to "score" this checklist because the answers are so variable. But in general, the more "right" answers you get, the better the therapy, and the better the therapy, the more likely you are to get better!

So, what if your proposed therapist did not score a Perfect "10"? Depending on the issues, you might still be far better off than if you prematurely elect a non-reversible therapy with a high risk of side-effects. As they teach in Massage Class, "Remember, any touch is better than no touch at all!" The only danger in getting BAD biofeedback is that you will not get better, but you'll think you have already tried and "it" failed. Maybe it wasn't the instrument or the patient, but the untrained therapist who is to blame.

One alternative is to find someone who is Very Good in either Biofeedback, or Nursing, or Physical Therapy, and encourage them to review this checklist (and the Glazer Protocol) and learn how to help you, and people like you. They may not realize how many potential patients are waiting for help.

To find out more about biofeedback in general, visit the website of the AABP - the Association for Applied Psychophysiology and Biofeedback. To find out more about the EMG Treatment of other pelvic muscle dysfunctions, check out the topics listed on the home page of InContiNet.

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