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| Functional Rehabilitation of Pelvic Floor Muscles: A Challenge to Tradition Howard Glazer, PhD, and Dawn MacConkey, PT, RCMT |
| Howard Glazer is a Clinical Associate Professor of Psychology in Psychiatry at Cornell University Medical College and an Associate Attending Psychologist at New York Hospital in New York City. Dawn MacConkey is a Physical Therapist at Physical Therapy Specialists in Denver, Colorado. Urol Nurs® 1996;16:68-9. Copyright © 1996 by the Society of Urologic Nurses and Associates Inc. We have found that the vast majority of patients referred to us for pelvic floor muscle rehabilitation have been given the traditional "Kegel" exercises by their physicians. Patients are typically instructed to identify the correct muscles by stopping the flow of urine and are then further instructed to "contract and relax" these muscles. On occasion, contraction duration and number of repetitions may be specified, but this tends to be highly variable. More often, instructions are simply to "do these exercises as often as you can" or "integrate these exercises into your daily activities." Few patients comply with these instructions, and of those who do, few receive significant benefit. Pelvic floor muscle control is a complex neuromuscular skill. This skill requires specific training including physiological feedback with specific exercise parameters to achieve a functionally significant, rapid, and long-lasting benefit.1 Based on our recent work with a wide variety of patients with urologic and gynecologic complications we have also come to challenge the traditional manner in which pelvic floor muscle control has been achieved by those specializing in the field. In the past, strengthening of pelvic floor muscles with surface electromyographic feedback has focused on isolating the pelvic floor muscles from their supportive accessory muscles (abdominals, adductors, piriformis, gluteals, etc.). We would like to challenge this tradition and introduce accessory augmented pelvic floor contractions (AAPFC) to enhance the rehabilitation of pelvic floor anal muscles in the treatment of urinary incontinence, detrusor instability, vulvodynia, interstitial cystitis, levator ani syndrome, prostatodynia, pelvic pain, and similar syndromes. We believe urology nurses are the primary teachers working with patients in regard to Kegel exercises and believe the AAPFC method will be of interest to them. The protocol does require surface electromyographic feedback, so special equipment is necessary because of the complexities of this training. Sophisticated technology does exist for patients who do not benefit from traditional instructions. Dr. Glazer initially began using accessory muscles to assist in pelvic floor rehabilitation in women with vulvodynia. In this population hypertonicity and instability of pelvic floor muscles are believed to play a significant role in sympathetically maintained stimulation of nociceptive fibers.2 Traditional forms of self-regulated relaxation were found to be ineffective in releasing tension in this muscle group, as were traditional localized pelvic floor contractions. Effective stabilization of pelvic floor muscles could be achieved, however, by fatiguing the muscle group through augmented voluntary pelvic floor contraction with accessory muscle groups.
The clinician can use the overflow phenomenon as described by Knott and Voss.3 In this case the augmented activation of pelvic floor muscle results from overflow of activating other muscles within the same functional unit (hip adductors, external rotators and flexors, and lower abdominals) either individually or in a D2 diagonal3 as shown in the Figure. This represents a more functional approach to the treatment of pelvic floor dysfunction. We have worked with pelvic floor muscles, both isolated and with accessories, using surface electromyography with an internal vaginal or anal sensor. What we have found is that patients who used accessory muscles obtained a much greater pelvic floor contractile amplitude much sooner. We were of course concerned about intra-abdominal pressure in our patients with stress incontinence. However, this did not prove to be a problem as long as upper abdominal contraction was separated from lower abdominal contraction. We trained patients to use accessory muscles until they felt an actual "lift" of the pelvic floor or "sucking up" of the vaginal sensor. Once the patient was able to sustain the pelvic floor muscle lift, accessory muscle use could be dropped out. In this way we could compare a "pure" pelvic contraction in these patients with that in patients who had been trained from the outset with exclusive use of pelvic floor muscles. We conducted a retrospective records review comparing 10 of our earlier patients trained with exclusive use of pelvic floor with 10 of our more recent patients trained with AAPFC. Each group conducted twice-daily 20-minute home exercise with surface electromyography feedback for 4 weeks, one group with accessory augmentation and one group without accessory augmentation. The results of comparing these two groups revealed 50% greater contractile amplitude of "pure" pelvic floor contractions in those trained with accessories over those trained without accessories (27 uv compared with 18 uv). It should be noted that in the clinical application of this protocol, we do not drop out the use of accessories for either practice exercise or use of the muscle group in daily living. We train patients with the AAPFC method to abort detrusor contractions, prevent intra-abdominal pressure-related involuntary urine loss, or break episodes of spasm. We encourage patients to use a more natural and functional contraction of pelvic floor muscles, permitting accessory muscles to support the contraction. In those patients trained with the AAPFC method, we found that the augmented contractile amplitude of pelvic floor was 185% (50 uv compared with 27 uv) of the "pure" pelvic floor contraction. This brief presentation does not allow us to elaborate on specific training parameters such as body positions, muscle-activating actions, or assessment and exercise protocols (for further information contact: Howard I. Glazer, PhD, 340 East 63rd St., Suite 1A, New York, NY 10021). We hope to simply introduce a more functional approach to pelvic floor muscle rehabilitation with accessory muscles to assist in increasing pelvic floor muscle strength more efficiently and more rapidly. Our clinical impressions are now being studied prospectively with an accessory assisted pelvic floor muscle strengthening program and a control group of isolated pelvic floor activity. A long-term follow-up of strength retention and symptomatic benefit will also necessitate evaluation. References
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We have gone on in our clinical practice to successfully apply
AAPFC to a wide variety of urologic and gynecologic conditions as listed previously. This
protocol can be used in all levels of pelvic floor weakness, not just the 0 to 1 grades,
and in all levels of pelvic floor muscle hypertonicity.