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This page leads to important articles, essays, and reviews about the non-surgical treatment of urinary incontinence and the new techniques available for the rehabilitation of pelvic muscles.
The entire field of pelvic muscle rehabilitation in the treatment of urinary incontinence has its origins in the work of a single physician, Dr. Arnold Kegel, a Obstetrician/ Gynecologist who practiced in the Los Angeles area starting in the 1940s. But Kegel did NOT invent the idea of using pelvic muscle exercises to cure urinary incontinence; that had already been suggested by Dr. Joshua Davies of New York City in 1932. Kegel's contribution was the invention of the world's first "biofeedback" device, about 1947.
His invention, the Kegel Perineometer (para-knee-om'-iter), consisted of an vaginal air-pressure cone or chamber connected by an air tube to an air-pressure gauge whose dial was calibrated in millimeters of mercury. The device enabled a woman (and her doctor-guide) to observe the strength and duration of her pelvic muscle contractions in order to learn truly effective exercise. (For a picture of the device, see Fig. 2 in the essay "On Sensor Size".) Over his career Kegel claimed to be successful in eliminating incontinence in 93% of some 3,000 patients. All of his patients used his biofeedback device on a twice or thrice-daily basis.
Over the years Kegel's exercises were described in nursing articles and passed down by word of mouth, but his perineometer device was never marketed effectively and his widow finally stopped selling them in 1979. Unfortunately, the success rate without biofeedback for so-called Kegel Exercises alone (or mere "verbal instruction alone") is only about 50% reduction in symptoms (leaks), and only mild and moderate cases can be helped at all without biofeedback. The history of this appropriation of his method without his device is described in an essay The Bastardization of Dr. Kegel's Exercises, by John Perry and Lesley Hullett (now Perry).
Since March, 1992 when the Agency for Health Care Policy and Research officially recommended that behavioral methods including biofeedback be utilized before drugs and surgery for urinary incontinence, most clinicians have used these Guidelines to document and justify opening "incontinence clinics". In addition, you may find helpful professional judgments to cite in two documents containing quotations from respected professionals in this field. Key Quotes on Perineometry provides references to Pelvic Muscle Rehabilitation in general and with EMG biofeedback in particular. Key Quotes on Urinary Incontinence deals specifically with the advantages of this method in treating urinary incontinence. (Use your browser's "back arrow" button to return to this page.)
The field of EMG perineometry began in 1975 with the invention of a new pelvic muscle sensing electrode that accomplished the same objective as the original Kegel Perineometer, but with a ten-old increase in sensitivity. This increased sensitivity makes it possible to use biofeedback training with muscles that are extremely debilitated - far below the level at which a physical examination (manual palpation) can detect contractions. Over a period of 15 years Dr. John Perry and Ms. Lesley May, MS, RN, developed The Perry Protocol to standardize the treatment procedures so that others could follow them, and thus generate multi-site research results that could contribute to the rapid advance of the field. Their protocol, which includes both office biofeedback and daily at home biofeedback practice (just like Kegel's own protocol) has proven much more successful than methods that eliminate one or the other aspect of the treatment. All of the new manufacturers of competing incontinence treatment systems have adopted this standard.
Originally the EMG pelvic muscle sensor invented by Dr. Perry was envisioned as a re-useable device that would last forever, or at least long enough to cure everybody who needed therapy. Unfortunately, first Herpes and then AIDS came on the scene and the need for a safe, single-patient sensor became apparent. The history and decisions that led to the new sensor are described in an essay The Rationale of the Single-User Sensor, written in May of 1995. Fortunately the production problems described there were finally solved in July of 1995, and sensors have been available in quantity from SRS and most major biofeedback distributors ever since.
Increasing patient compliance is often a concern of behavioral therapists. Many early attempts to use biofeedback in the treatment of incontinence were only marginally successful because clinicians were not able to generate enough motivation in their patients to reach significant levels of exercise; so results slowed and patient enthusiasm declined even further. The Patient Hotline is an essay that describes how to utilize an inexpensive "incoming-only" telephone line and a used telephone answering machine to create an automated patient reporting station that increases compliance and helps stop motivational problems before they sabotage the whole therapy.
Many clinicians have experience patients who appear concerned about the "size" of the vaginal or even rectal sensor EMG sensor, so an essay, "On Sensor Size", was written to address those concerns. It is important to balance technical concerns about accurate measurement with patient concerns, and to use the most appropriate size sensor for each patient.
Hardly a month goes by without some clinician stating that they "don't use home trainers because there's no research that shows they are necessary." The paper The Role of Home Trainers in Kegel's Exercise Program, published in the peer-reviewed journal Ostomy/Wound, compares programs that did and did not utilize home trainers, and who got the best results.
The Kegel Perineometer: Biofeedback 20 years Before Its Time is a short paper which explains that Kegel was the first to use biofeedback, 20 years before the term was coined. This paper was accorded "Special Historical Paper" status at the 1989 (Twentieth) Annual Meeting of the Association for Applied Psychophysiology and Biofeedback (AAPB).
Many other papers are in the process of being transferred to this website. Please let us know your interests.
Many clinicians have requested help in explaining EMG biofeedback therapy to Insurance Companies who appear ignorant of recent advances in the treatment of incontinence. As a result of many requests, Dr. Perry prepared a "Generic Insurance Letter" which deals with some of the common third-party misunderstandings, such as "biofeedback is 'investigational'" and "nurses should not be doing this work". Download this document and print it, or edit it and paste sections directly into your own insurance appeal letter.
Click on these titles for details:
Beyond Kegels (The Book) - 160 pages, 60 illustrations - New Exercises for Incontinence
Beyond Kegels: Endopelvic Exercises (The Video) - 50 minute Color Video
Anatomy Teaching Aides for Incontinence - 8 laminated full-color teaching diagrams
Beyond Kegels Home Program Handouts - pads of illustrated exercises and diary
Pheonix Seminars Schedule for 1998 - on Incontinence and Fibromyaligia
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© 1997 by John D. Perry Last Edited on April 17, 1998
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