Chapter 3-b (IBM Version)
John D. Perry, Ph.D.
Biofeedback Institute
of Philadelphia
Model CP-330
Version 0.90
12/31/87
Important: This Chapter is provided for
historical interest only.
The most recent version of this manual
is available on this website as SW330man.htm.
CP-330 is a computerized version of the Clinical Perineometer™
(Model CP-100) which was designed by Dr. John D. Perry and William
Farrall, and is manufactured by Farrall Instruments, Inc. It provides
the same "flick", "hold" and "endurance"
tests, and provides a summary printout of results. Like the Clinical
Perineometer™, it conforms to Dr. Perry's "Software
Standards for the Electronic Perineometer (1984)", the internationally
recognized data collection and reporting format for pelvic muscle
work. In addition, the CP-330 program provides a unique biofeedback
practice program, the "Kegel Counter", which permits
the therapist to define a "valid" practice contraction
for a particular patient; then the program guides the patient
through a pre-determined number of criterion-referenced exercises.
The program is a specialized "Application" of the J&J
USE system which is supplied with the J&J I-330 (IBM) Interface
and modules. It is, in other words, a specially configured and
supported version of the USE system. Many of its features are
user-adjustable, but you should be cautious not to change features
such as diagnostic timing and sequences which would cause your
data collection to deviate from the International Standards.
The J&J USE system is uniquely sold in an "annual subscription"
format, which means that it will be continually updated and improved
for at least one year. This application follows the same format.
Each time J&J issues an upgrade, we will issue our own upgrade,
incorporating the new features that have become available.
For example, we have already received beta-test versions of release
0.93, which includes a feature called "Virtual Channels",
and are now working to include this feature in the next release
of the PerryMeter™ system. [Virtual Channels means that we
can "create" a virtual (or artificial) channel for display
that is composed of two or more "real" channels in a
certain mathematical relationship. Specifically, we will be able
to show the "Net" EMG level of Kegel Exercises, on a
"Virtual Channel" that is created by subtracting accessory
muscle activity from pelvic muscle activity!] Version 0.93 also
includes 0.1 second averages (instead of 1.0 second minimums),
which will permit finer determination of flick "maximums".
The program is designed to run on (1) an IBM-AT [or "Turbo
XT"] computer, such as the Physiodata 286 available from
Biotechnologies, Inc. It requires (2) a Hard Disk (at least 10
and preferably 20 or more Megabytes), (3) one or more floppy drives,
(4) a color graphics board and color monitor (preferably EGA type),
(5) a graphics printer (preferably with color, such as the Okidata
292), (6) a J&J I-330 Interface and two Model M-501 EMG preamplifier
modules. [Additional modules may also be very useful when using
the program.] A serial port is required for the J&J interface,
and a parallel port for the printer.
LOADING THIS PROGRAM ONTO
YOUR COMPUTER'S HARD DISK
General Directions for loading any "APPLICATION"
such as this one into your computer are given in the J&J I-330
Manual in section 1.4.4. [Disregard all references to "floppy
disk systems", such as section 1.4.2; this application is
much too large to run off a floppy disk system.]
Step 1: USEDISK
Section 1.4.4 instructs you to follow the directions
in Section 1.4.1 for making a hard disk system. You will be instructed
there to use the program USEDISK (which is usually found on the
FIRST OPTION DISK of the J&J set of disks).
The USEDISK program is invoked by inserting the First
Option Disk in drive A, logging onto drive A [by typing A:<ret>],
and then typing USEDISK<ret>. You should follow the instructions
on the screen. Select option "H" for Hard Disk installation.
When asked for the "Number of System Diskettes received from
J&J", count BOTH the J&J disks [five of them in release
0.90 on 5.25" media] PLUS the disks marked "PerryMeter™"
[two of them in release 0.90, for a total of Seven (7) diskettes
as the correct response to the question].
Normally you will select drive "C" [your
boot hard disk] as the destination drive when USEDISK asks for
a choice. However, you can use other drives or partitions of drives
if appropriate in your circumstances.
Alternative Installation:
As an alternative (or if you already have a USE directory
installed and available) you can also install the PerryMeter™
system using standard DOS commands. This may be necessary, for
example, if your J&J USE disks and PerryMeter™ disks
are on different media (sizes), making it impossible to specify
a single "source" drive for all diskettes under USEDISK.
In this case, first load the J&J USE system onto drive c: using USEDISK. Then log into your new directory (e.g., cd\usea) and copy all the files on the PerryMeter™ distribution disks from drive A: with the "wildcard" copy command:
copy a:*.* c:\usea [After the first disk is copied,
repeat this command for the second disk as well.]
Note that in some combinations, PerryMeter™
system files will over-write the generic J&J system files,
so you won't be able to "go back" and use the original
J&J system; it will have been converted to this application.
Important Hints and Tips:
You should note that the J&J Menu Selection program
[JJ.COM] which you will later be using to start up this (or any
J&J) application looks for any and all USE programs and applications
on the same disk drive that it (JJ.COM) is on. Each USE system
or application is installed in a separate "directory"
whose name starts with USEx. The USEDISK program, once it is told
which drive to use as the destination, scans that drive and reports
the names of "available" USE directories. If this is
the first installation on that drive, it will report that the
first available directory is "\USEA". But if you already
have one USE system (directory) on that drive, it will report
that the first available one is "\USEB" (etc.)
USE systems (and their corresponding directories
on a disk drive) must and will be created alphabetically starting
with A, B, C, etc.
Any JJ.COM program (for example, the one residing
in the \USEA directory) will "detect" all USE directories
that might exist on the same disk drive (but not on any other
disk drive). [The application name and its loading instructions
are stored in a small file called "APNAME.TXT"; there
should be only one such file in each directory.]
We suggest that you plan to install not one but two
identical PerryMeter™ (USE) systems (directories), such as
"USEA" and "USEB". Keep the first one in its
original form; never "save" any program changes there.
Use the second one for experimenting with new colors, combinations,
etc. Only after you have fine-tuned and de-bugged a new combination
or sequence in the second directory should you risk modifying
the "original" distribution version.
If you do destroy the program in your original USEA
directory, you can always re-load it from the Master (distribution)
diskettes, using USEDISK. But note that you will have to remove
(trash) the damaged files and remove the first directory entry,
or USEDISK will think that that letter of the alphabet is already
"taken" and assign a (replacement) installation as a
new "USEC" (in this example).
If you install more than one USE system (directory),
note that you will have to change directories to each of them
in turn and run the USEINST (installation) program from within
each directory. (See Step 3).
If you wish to follow the tutorial instructions in
the J&J Manual, we suggest that you install a Third "USE"
system (directory), \USEC, in order to carry out the tutorial
steps. If you have the PerryMeter™ standard "55xx"
box, you won't be able to fully appreciate the displays that were
designed for slower-moving signals like temperature (Module Number
6), but you will learn from the investment of time.
Step 2: USETEST
After completing the installation in Step 1, turn
to Section 1.5 in the J&J Manual and follow the testing instructions
there.
NOTE: The instructions say to change directories
to USEA [cd\usea], but you should substitute the appropriate letters
for the installation you just did in Step 1 above. C:cd\usea would
be appropriate only if this were your first installation of a
USE system.
Step 3: USEINST
If the system checks out in Step 2, proceed to Section
1.6 to "install" this version of the USE system. See
the note above and make sure you are in the correct directory
(USEA, USEB, USEC, etc) first.
Model Numbers: If you are installing only a PerryMeter™
incontinence treatment system, you probably have only one "box"
with two EMG modules; you will want to set up a "55xx"
configuration. [Otherwise, consult your J&J manual to determine
the proper configuration for your "boxes" and modules.]
Follow the remaining instructions for the installation
program.
PATH SPECIFICATIONS: (Section 1.6.14) In general,
you will need to specify paths for the same drive that you selected
in the USEDISK program in Step 1. You do have a choice of putting
patient data on a floppy disk, such as "Drive B:", which
is entirely a matter of personal preference. [Note that if you
decide to store patient data on floppies, you will have to insert
a properly-formatted floppy in the specified drive before accomplishing
any "save to disk" functions later.]
You may disagree with the manual's advice and find
it easier to store data on drive c:. Periodically such data files
can be copied to floppies using wildcard DOS "copy"
commands. On the other hand, there is some risk to keeping data
on a hard disk. If you keep valuable data on your hard disk, you
will need to institute regular "backup" procedures.
We once lost six weeks' work when a hard disk "crashed".
When a second hard disk crashed in the same office next month,
we only lost a couple of days work because that one had been properly
backed up! A word to the wise...
Starting Up
There are two ways to start up. If you have multiple
USE systems on your drive, you can enter JJ at the prompt and
then select by letter the system you want to use. (You have to
be in some USE directory to do this, or put one in your DOS "PATH"
command file.)
Alternatively, you can first make sure you are in
the correct directory [cd\usea, for example] and then simply enter
USE<ret> as explained in Section 1.7 of the J&J Manual.
TITLE PAGE
The J&J Title Page (with a rainbow banner near
the top) identifies the Program, checks the interface connections,
reports the Version number, and then loads the Volumes and Volume
Sequences that make up this application.
MAIN MENU PAGE
There is only one option: the Letter "P"
should be pressed to select the PerryMeter™ Perineometry
System.
PERRYMETER TITLE PAGE
At this point you have entered the application proper.
The normal thing to do is "Press INS Key (Insert Key on the
keyboard) To Start Program". However, you could also press
<ALT> and "V" at the same time, and a pop-up "Change
Volume" Menu will appear in purple. You can press <ESC>
to exit (return to the title page), OR you can select any ONE
of the "Volumes" that make up the "Volume Sequence"
[or Main Menu] that is called "P-PerryMeter Perineometry
System".
Before moving on, note that these "Volumes" are arranged in groups: first volumes A,B,C,D, & E which comprise the Diagnostic Tests; then the K-Kegel Practice and Logo Screens; and finally a group of option screens (including games and special purpose screens). If you select any one of these by its letter, you will get only that volume. Under certain circumstances, that might be what you want. Normally, however, you will want to run the standard diagnostic sequence (ABCDE), pause for review, discussion, data-saving, and/or printing, and then move directly to Kegel Practice (K), followed by review, discussion, data-saving, and graph or numeric printing. The "Volume Sequence" or Main Menu entry "P-PerryMeter Perineometry System" provides that combination in an automatic sequence. (Press <ESC> to erase the purple page and <INS> to start the automatic sequence now.)
DIAGNOSTIC TESTING
After an explanatory screen ("Get Ready" phase, on for
about 15 seconds), a grey graph is displayed and you can observe
the patient's resting (baseline) level. The graph is called "Warm-Up"
and you will observe that no data is being recorded ("recOFF"
is displayed in the top "status" line). An unlimited
number of 10-second graphs are drawn and erased in this phase,
while you confirm the connections and wait for a good baseline.
A good baseline is under 1.0 microvolts. A reasonable baseline
is under 2.0 microvolts. However, if the patient is especially
apprehensive, or suffers from chronic pelvic tension, readings
may be as high as 3 or even 5 microvolts. Under these conditions,
it is best to focus on relaxation for a few moments-or longer-before
proceeding with the evaluation.
High baseline levels could also result from mechanical or electrical
problems. A reading of "155" or so is usually caused
by a broken (open) EMG lead. Readings of 30 to 100 microvolts
are virtually impossible, and should cause you to suspect that
either the sensor is not fully inserted, or that the vagina or
rectum is exceptionally dry (not making good contact) or exceptionally
wet (due to either sexual arousal {vaginal} or use of excessive
lubricant {rectal} when inserting the sensor.
If you obtain a "reasonable" baseline, it is probably
safe to proceed with the testing. If the baseline is over 5 or
10 µvolts, however, you should test for electrode continuity
the same as you would with surface EMG electrodes Ð with an
ohmmeter connected across each possible pair of electrode leads
(A-B, B-C, A-C). All lead combinations should show less than 20K
Ohms for reliable results. Repositioning the sensor, reinserting
it; substituting a light-weight "single-patient perineometer"
sensor, or moving to a rectal placement are all possible alternatives.
We have seen problems, for example, with patients wearing very
tight bluejeans Ð which forced a sensor to "twist"
sideways in the vagina, enough to permit one silver pad to break
contact with the skin and give false-high readings.
When the patient is stable and reasonable values are displayed,
press <INS> to move to the next stage.
FLICK TEST (Vol. B)
The Flick Test measures the PEAK EMG level obtained in a pelvic
muscle contraction. It is of dubious clinical merit, since it
has not been shown to be a reliable predictor of anything. However,
there is still one good reason for obtaining this measure: if
a person scores much higher on Flicks than Holds, you know that
(1) they've been doing Kegel Exercises and (2) they've been badly
instructed in the past, so that they have only practiced short
contractions. Another reason for measuring it is that's what everyone
used to measure using the Kegel Perineometer in the old days.
Three "baseline" screens of five seconds each are displayed,
during which the patient should remain as relaxed as possible.
Note that this data is being recorded in the computer's memory
("rec ON" is displayed in the status line, and a black
background is used.)
Six 5-second screens are presented. The patient must be instructed
to make one quick contraction on each of the six screens. The
highest values obtained on each screen will be of interest.
Three 5-second "post-line" screens are presented, to
observe if the resting tension level has changed appreciably as
a result of doing the "flicks".
Technical Note: The Pre- and Post- line screens are "Periods"
of 3 "Trials" each, as you will observe if you press
the F5 key while in the Flick Test (Vol. B). As such, you could
pause at the end of any 5-second screen by pressing the spacebar,
as explained in the J&J manual. The Six Flicks, however, are
"Periods" of a single "Trial" each, so no
pause is possible. On the other hand, note that the <DEL>
(delete) key can be used to abort and restart any trial (before
it is completed). If the patient seems to have difficulty making
a flick, you can abort and re-do any (or all) of the six flick
screens by pressing the <DEL> key during the last second
of the screen.
HOLD TEST (Vol. C)
The program next automatically administers five cycles of 10-second
Rest and Hold Measurements. This is the single most important
measurement, and the only one which significantly correlates with
urinary control and sexual response in published research. If
you only use or cite one measure, it should be this one.
The Program alternately presents Rest and Hold screens in five
cycles, labled "1 REST", "1 HOLD", etc., through
"5 HOLD". A beep sounds each time the instruction changes.
You must verbally inform the patient to "Relax" and
"Contract" for each screen.
(We have been promised a "split-screen" display that
will permit these instructions to be printed on the screen in
large letters, but it is not yet available from J&J. It will
be incorporated as soon as it becomes available.)
Note that the <DEL> key can be used here to re-start any
screen ("Trial"), if pressed before it is completed.
When that happens, the new trial simply replaces the aborted one
in memory.
General Comments on the Hold Test: It is tempting to comment on
the patient's progress, but restrain yourself while the Hold Test
is going on. The patient must concentrate. Use your free time
to observe whether the patient is using accessory muscles, holding
the breath, etc. Make the testing situation as "standard"
as possible. Patient education is most effective if offered during
the practice modules.
ENDURANCE TEST (Vol. D)
The endurance test consists of a single 60-second graph during
which the patient is instructed (by the computer and by the therapist)
to make and sustain a strong contraction as long as possible.
Here the pattern of fatigue can be graphically seen. The therapist
should mentally note the highest level obtained, and observe the
time the EMG level takes to drop to 50% of that. The same information
is also available in the data summary.
POST-TEST RESTING PHASE (Vol. E)
After calculations are performed, a complete graph ("Review")
of all the diagnostic data collected in now displayed. The graph
is held on the screen indefinitely, so that (1) the therapist
can discuss the results with the patient and (2) if desired, make
a graphic printout.
If you are using a color graphics printer such as the Okidata
292, you should probably initiate a screen dump (Shift + PrtSc
keys) right away, since it takes some time.
Things to Observe:
You will want to point out to the patient any outstanding features,
such as: (1) height (strength) of holds, (2) consistence of holds,
(3) comparison of flicks and holds in height, (4) changes in pre-
and post- resting levels, (5) consistency of rests, and (6) decline
or fatigue shown in "timing" test.
It is important to be positive in your presentation of the results,
especially when the muscles are weak. One approach is to stress
that the results are wonderful, because they are so terrible.
That is, the muscles are definitely weak, and thus clearly account
for the patient's problem. That's good news, because weak muscles
can be readily trained with biofeedback, and that means the patient
can get better, probably without surgery or drugs. The answer,
of course, is biofeedback-assisted exercise, which by no coincidence
happens to be next.
When you are finished discussing this screen, press <INS>
to advance to the Kegel Practice section.
Alternatively, you can now press F4 to move to the
data review menu and save the diagnostic data to disk. You would
do this now if you do not intend to also save the data generated
in the practice section which comes next. Diagnostic data should
always be saved; saving practice data is a matter of local preference.
PRACTICE MODULE
Kegel Practice (Vol. K)
In the Kegel Practice section, patients are presented
with a series of twenty-five 20-second screens. On the left half
of each screen, the patient is instructed to relax as fully as
possible. After 10 seconds, a vertical line is drawn and the patient
is instructed to contract the pelvic muscle as strongly as possible.
Each 20-second screen presents two "trials";
an odd-numbered trial on the left side of the screen, and an even
number trial on the right half. Later, in data analysis, it will
be obvious why this is done.
On each screen, an upper "contract" criterion
line (yellow) and a lower "relaxation" (cyan) criterion
line is drawn. Whenever the EMG signal is between these two lines,
an audible tone sounds. This is a "no-persons's land",
and the tone is intended to be slightly aversive and certainly
attention-catching. When relaxing (on the left half screen), the
EMG should be below the cyan relaxation lineÐand the tone
off. When contracting (on the right half screen) the EMG should
be above the yellow lineÐand the tone off.
At this point, some technical information is necessary.
Notice that there are now, for the first time, two identifying
legends at the bottom of the screenÑbut one is yellow and
the other cyan). The dual-threshold, which has proven so useful
in teaching Kegel exercises, is unknown in other biofeedback applications.
We used a simple trick to accomplish it in the USE system. We
arranged to display two signals simultaneouslyÑboth of
them derived from Module A1. One, displayed in yellow, sets the
contract criteria. The other, displayed in cyan, sets the relax
criteria. And the audio tone is set to come on when two conditions
are met: it sounds only when the EMG is BOTH below the yellow
and above the cyan lines; i.e., in between.
If you've read the J&J Manual, you know that
the thresholds can be changedÑon the "active"
channelÑby depressing the + and - keys. The "active"
channel is the one with the "happy face", and is selected
by pressing the <TAB> key.
You can also change the range or scale of the graph
by using the 6 and 7 keys, but note that you must change both
signals (yellow and cyan) the same amount or the two signals will
no longer appear superimposed but will separate. In practice,
its not difficult to do. Usually you will want to make the screen
more sensitive for a particularly weak patient. To do this, simply
press 7, <TAB>, and 7 in sequence. Then you will probably
want to press <TAB> and then - several times to bring the
yellow contract criteria line down. Finally, you might also press
<TAB> and - again to bring the cyan relax criteria line
down, too. (If you go too far, just press + a few times. These
levels can be changed at any time; just observe where the happy
face is before pressing the key.)
Remember when setting criteria that the object is
to enable to patient to reach the goal about 80% of the time.
If too easy, they won't extend themselves. If too hard, they'll
get quickly discouraged.
When the twenty-five screens have been displayed,
(it's only 8 1/3 minutes!) the program automatically jumps to
a "SUMMARY" graph screen which shows the (hopefully)
saw-tooth pattern of 25 relaxations and contractions.
You can also display ALL DATA in the computer's current
memory in a single graph, by pressing the cursor-down-arrow key
twice. Some may prefer this option, while others will consider
it too compressed.
If you choose, you can dump the summary graph to
the printer with the <SHIFT> + <PrtSc> combination.
You may also discuss the graph with the patient now.
Normally, the next step (while the summary graph
is displayed) would be to save the data to disk, unless you elected
to save only the diagnostic data at the end of Vol. E, above.
Press F4 to get to the data storage screen.
Other Considerations: The Kegel Exercise practice
program ("Vol. K") can be repeated if desired; just
press <ALT> + V and select option K. from the menu.
You can change the number of 20-second Kegels cycles
from the established 50 to any (even) number, to suit scheduling
convenience as well as patient needs, by following the directions
for "programing" (F5 key) and "saving" (F6
key) your new Volume K. We caution against making office practice
sessions too easy, however. The Kegel Exercises are not an alternative
to "reading a good book" Ð they are an alternative
to surgery, drugs, and the psychologically damaging effects of
incontinence. We tell our patients "Sure you have to work
hard now. But when you get your muscles back in shape, you'll
be able to cut back to an easier maintenance level. The harder
you work now, the sooner you'll get better."
DATA STORAGE AND PRINTOUT
We are presently preparing a set of standard data
handling routines for summary reporting of the patient activity.
In the meantime, the standard J&J options and manual programming
mode may be used to review patient data.
Observe that a variety of measures are needed. For
pre- and post- flick baselines, and for holds, the mean and standard
deviation of the period is appropriate. For flicks, the maximum
of each trial is of interest. For endurance, the pattern of the
60 averages must be analyzed to determine the 50% endurance level.
For Kegels, the mean of the 25 odd-numbered trials must be compared
to the mean of the 25 even numbered ones.
Clearing Memory of Saved Data
It is important to understand that the computer blindly
stores data upon command, without any regard for the meaning which
we will attached to that data. The computer doesn't even know
when we change who's hooked up to the modules, so be sure to let
the computer know!
Most patient sessions should end on an "F4"
data-saving screen. Notice that you have the option of pressing
"E" to erase all data from memory before returning to
the program. If you have data that hasn't been saved, a warning
message will be displayed reminding you. If the data is real/valuable,
be sure to save it now. But if the data is not (as, for example,
if you were "testing" the system before a patient arrived)
be sure to clear out memory before starting to collect new patient
data. Until you erase memory, the computer will keep blindly accumulating
data, adding it onto what's already there. Later there will be
no way to separate the "real" data from the false, when
you save the patient data to disk.
The Safest Course is to always restart the Program
from scratch for each new patient. If in doubt, you can always
press F4 and look for the flashing red "No Data Recorded
Yet" message.
A Warning about "Sequences"
Once started, a "volume sequence" or main
menu entree, such as "P-PerryMeter Perineometery System",
automatically advances from one volume to the next. If you interrupt
the process by selecting a volume directly from the ALT-V (volume)
menu, the interrupted sequence will pick up again after your selection
is finished. Therefore, if you wish to terminate the automatic
sequence, you should first press <ALT>+M to get the Main
Menu back. You will notice a new bottom line in white: ">>>Sequence
in progress---type X to exit". Just press X and you will
be released from the automatic sequencing. Then you can press
<ALT>+V to select other volumes.
OPTION SCREENS
Several optional screens are available as choices
on the ALT-V menu. These may be selected as appropriate. Note
that the Egg Catching and River Raft games are especially valuable
for teaching muscular control; the Pyramid screen is suitable
for very weak muscles; and the Contracting Circle screen has an
idiopathic appeal for variety.
Each screen ends with a "review" data display,
although the meaning (and usefulness) of such a display will vary
depending on the situation.
ON-LINE HELP
At most points throughout the PerryMeter program,
on-line help is available by pressing the <Return> key and
following the instructions printed there.
In addition, a wide range of HELPS is available as
explained in the J&J Manual. ALT-H provides specific descriptions
of features, while ALT-K shows the functions of keyboard controls.
Miscellaneous. Notes.
This manual is intended to be used in conjunction
with the J&J I-330 Instruction Manual, which includes information
about the USE system and technical information about the I-330
Interface and the M-501 EMG Module.
TIP: If you are giving a demonstration of the EMG
Perineometer and holding it in the crotch of your hand to simulate
EMG signals, you may find it difficult to relax your hand to a
"normal" level of 1-2 µV without dropping the sensor.
If you put the bottom switch on the EMG "down", you'll
multiply the displayed values by 10, and give a more impressive
demonstration. But one word of warning: Don't forget to return
the switch to its normal position after the demonstration, or
you may totally mis-diagnose your subsequent patients, with serious
consequences!
Please note the section in the J&J Manual concerning background noise testing with their dummy electrode assembly. We recommend using this to test for electrical interference. Note that the interface should be kept 1 to 2 feet away from the computer. Moreover, anything connected to the interface should also be kept a couple of feet away from the computer Ð including the patient! One common violation of this rule occurs when the patient's feet are too close to the video monitor. If there is a poor "reference" lead connection and the patient's feet are close to the monitor, there will be pick-up of electromagnetic radiation from the screen which shows up as background noise (high resting tension) You can prove the source of such interferance by turning down the screen brightness and noting if the signal noise level goes down in proportion. If this happens, move the patient and monitor farther apart.
This page is www.incontinet.com/articles/art_urin/HOPCP-300.htm
Copyright 1996 by John D. Perry
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