Version 1.1 Rev. 2/95
Preamble
The Perry Protocol was developed out of fifteen years experience in treating patients with urinary and fecal incontinence in hospitals, clinics, and private practices in the United States, Europe and South America. It represents the collective wisdom of hundreds of practitioners who have utilized the PerryMeterȘ System of EMG sensors, computers and related instruments in treating thousands of patients with incontinence problems. The protocol was tested for two years at the authors' out-patient Continence Program at Paoli Memorial Hospital in Pennsylvania. It resulted in significant improvement over less rigorous protocols; 99.95% symptom reduction, 98% total symptom relief, for 56 patients (California Biofeedback, Summer, 1988).
The Protocol is addressed initially to clinicians, to provide a detailed explanation of the methods that have been successfully employed by their colleagues in the treatment of incontinence.
It is also addressed to researchers, to provide a sound basis for replication studies and a point of departure for methodological improvements. It also provides much-needed standards for data collection and reporting.
Finally, it is addressed to "third parties", whose experience with biofeedback may be limited to relaxation training and who need to understand the new application of internal surface EMG to muscle rehabilitation problems. EMG Perineometry promises to drastically reduce the need for surgery for most incontinent patients, and to significantly improve the outcome for those patients who do require surgery.
This document will be revised regularly through peer review and collaboration; for the latest edition, contact The Perry Institute at 3620 Sunrise Drive, Key West, Florida, 33040 U.S.A. (Telephone 305-294-4688).
© 1990-95 by John D. Perry, Ph.D., & Leslie B. Talcott, M.S., R.N.
A. Patient records are reviewed at each office visit, and discussed with the patient.
1. Tabulations of "accidents" are calculated and compared to detect trends and reward progress.
2. Patients who do not keep adequate records are ejected from the program (usually after a warning).
A. The Standard Evaluation consists of a series of six 10-second contraction periods, with six 10-second rest periods interspersed; i.e., 6 x (Contract+Rest).
1. Whenever possible, the patient is evaluated in a naturalistic situation; fully clothed and seated in a comfortable chair.
a) Typical exceptions may include the very young, very old, and those with restricted mobility.
2. A vaginal or rectal EMG perineometer is used to monitor EMG activity. Whenever possible, the sensor is self-inserted by the patient.
3. The Electromyographic activity of the pelvic floor is reported in RMS (root-mean-square) microvolts.
4. For psychometric purity, the program should discard the highest and lowest interval scores and calculate the arithmatic mean of the remaining four scores.
B. The Standard Measure of Resting Level ("tension") is the average value of the rest periods.
1. A typical resting level is somewhat below 2.0
2. A good resting level is somewhat below 1.0
a) The resting level should also be compared to a pretesting baseline measure to ascertain the possible negative effect of performing contractions.
C. The Standard Measure of Contractile Strength is the average value of the contraction intervals minus the resting level (from above).
1. A typical non-patient contraction level is 10.0 ”V.
2. A good non-patient contraction level is 20.0 ”V
a) The standard deviation is an important indication of tonic contractile ability. Conversely, a high standard deviation indicates a high proportion of phasic muscle fibers.
b) Rectal measures are typically slightly higher than vaginal measures.
c) Sphincter strength is proportional to overall bodily strength; it is estimated to decline by 50% by age 75.
D. Neuromuscular Control is defined as the latency, in seconds, to reach stable contraction and relaxation levels.
1. Recruitment latency under 0.5 seconds is typical of non-patients.
2. Relaxation latency under 1.0 seconds is typical of non-patients.
E. Additional Computerized Tests, Features and Options may increase diagnostic and/or therapeutic abilities as the become available.
A. Patients are instructed to perform l0-second contractions with l0-second rest periods in between.
1. Some geriatric patients with extremely weak muscles can be started on shorter contractions for the first week or two.
2. Short contractions (historically known as "flicks") are never prescribed, since they do not create tonic muscle fibers.
3. Operational descriptions are preferred over logical ones; i.e., the patient is instructed to "make the meter go up" rather than "imagine an internal elevator".
4. The biofeedback device should be calibrated so that the patient can know and record actual performance on an objective scale.
B. The minimum amount of exercise is two 20-minute practice periods each day.
1. Some geriatric patients may have a reduced assignment for the first week or two.
2. The patient is encouraged to add a third 20-minute period whenever possible.
3. If progress reaches a plateau before a cure, a third daily practice is then required.
4. At one hour per day, the average patient (out-patient clinic, without other med-psych complications) will be symptom-free after less than 60 hours practice.
C. Patients are trained to criterion, not merely to symptom relief.
1. The patient is not expected to show symptom improvement without first showing significant improvement in resting level, contractile strength, and neuromuscular control.
2. Patients below norms for their age and condition are over-trained until their scores are at least nearly normal, so that they will not relapse at the first systemic threat (e.g., flu, hormonal cycle variations, etc.)
A. Office evaluations are conducted weekly for 2 or 3 visits, until correct exercise patterns and substantial Improvement in EMG levels are obtained; then biweekly and sometimes triweekly through termination.
B. The complete diagnostic evaluation is performed at every office visit, and the printed results compared to previous visits and delivered to the patient.
C. A Kegel Exercise practice session is also conducted at each office visit. The therapist especially monitors the patient's breathing patterns and the possible use of accessory muscles.
1. When necessary, a second EMG channel and traditional surface electrodes may be used (on the offending muscle) to show the patient the contribution of the accessory muscles (and how to eliminate them).
A. When (or if) patients fail to show weekly improvements in muscle contraction scores (EMG) and weekly declines in "accidents", the prudent therapist inquires into the cause of the problem
1. Patient progress is compared to known norms for treatment duration, based on published studies, but allowing for differences in baseline populations.
a) Treatment durations are expected to be longer for those patients with concomitant medical problems; systemic diseases (e.g., M.S.), and psychological stressors (e.g., recent loss of spouse).
2. The most common cause of lack of progress is lack of exercise.
B. Beginning early in the second or third session the patient is taught behavioral principles of generalization.
1. The patient is instructed to perform exercise in a variety of positions, from supine to seated to standing to walking.
2. The patient is encouraged to begin doing additional Kegel Exercises, without the aid of the biofeedback device, throughout the day.
3. The patient is taught appropriate behavioral interventions, such as squeezing before coughing or lifting.
A. Related issues, such as diet and nutrition, exercise, relaxation training, psychological and sexual counseling, are included in the over-all therapy program as needed.
B. To the extent that such related issues fall outside the expertise of the primary therapist, appropriate referrals are made to other professionals, with follow-up monitored.
C. The competent therapist participates in the international professional community through attendance at meetings and reading of professional literature
D. "Certification in Perineometry", as awarded by the Perineometer Research Institute [Now "The Perry Institute"], is one measure of professional competence recognized by hospitals, professional societies, and third parties.
(©)1990 by John D. Perry
In order to scientifically compare incontinence research projects it is necessary to have comparable populations. Obviously the results at an Ambulatory Out-Patient Clinic (e.g. average age 45) can be expected to be different from a Nursing Home (e.g., average age 89); likewise, both will be different from an in-hospital services that sees patients only post-operatively. It is advisable to differentiate between these groups in a meaningful way. For example, one might report that "30 Class I patients did X, whereas 20 Class III patients did Y."
Rule: All patients are "Class I" unless they qualify for a another class.
In order to make the Classification System mutual exhaustive, all patients are Class I unless there is reason to put them in another class.
Rule: Patients are classified as of the END of Treatment.
Unlike surgical patients, in behavioral therapies it is not unusual for a patient's classification to change over time as a result of external events. The patient's condition at the end of therapy will have the greatest influence on the outcome.
Patients in whom urinary or fecal incontinence (or retention) is a clear result of another acute condition are Class 0. Their incontinence is only a temporary side effect of another disease or condition, and the incontinence is relieved when the primary condition is resolved. Examples include incontinence as a side effect of medication, impaction (other than anismus), temporary immobility, etc. [see Resnick's classification]
Class I patients may have other medical problems ranging from angina to shingles, but the condition is not believed to have any direct causal effect on the incontinence. Patients with "anatomical stress incontinence" (i.e., sagging perineum) and "hyper-reflexive bladder" (i.e., uninhibited bladder) are Class I.
„ Sub-Class II-A Compromised by An Acute Condition
As a result of local injury due to accidents
One over-weight Class I patient was making good progress towards recovery of continence until she was in an automobile accident in which the steering wheel was jammed into her abdomen; her therapy was extended for several weeks as a result.
One elderly Class I patient was making good progress until she fractured her hip in a fall and had to drop out of the program.
As a result of local injury due to surgical intervention
„ Post-Prostate Surgery males, Post-hysterectomy and laporscopy females fall into this class.
„ Sub-Class II-B Compromised by A Chronic Condition
The range of compromise resulting from all chronic conditions is extreme, and probably warrants further subdivision. Some patients appear only mildly affected, while others are severely affected. Examples of chronic conditions are:
Multiple Sclerosis
Diabetes, neuropathy resulting from.
CVA (Stroke)
Multiple Pelvic Surgery
The presence of significant scar tissue resulting from previous pelvic surgery, especially A&P repairs, suspension procedures, etc. always complicates relearning of pelvic muscle control and rehabilitation.
Myofascial Restrictions
Patients with severe scar tissue, pelvic imbalances and similar problems often become incontinent as a result of chronic pelvic pain. The incontinence usually cannot be treated apart from the chronic condition.
Disruption of Sexual Life
Incontinence often follows within 6 months of disruption of a previously active sexual life. The most common precipitating events are (l) partner's heart attack and (2) partner's prostate surgery. This condition results when the patient's response to the event is sudden denial of need for or interest in sex, suddenly reversing a life-long pattern.
Elderly patients not in good health
Patients in a general state of physical decline due to the aging process. Age-related chronic conditions, such as Altzheimers Disease and Parkinsons are classified here, rather than in the less-age-related Class II-B.
Nursing Home Residents
Nursing Home residents are characterized by no longer being able to fully care for themselves. Their treatment is therefore additionally dependent upon the quality of professional care which they receive, and not simply upon their own basic health.
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