Often the most significant discoveries are serendipitous, and the present case study is a prime example. The subject was a 21-year-old college student who wanted to earn $25 by participating in basic "Masters and Johnson" type sex research. But on the appointed Saturday morning she appeared at the laboratory with a tortured look on her face. "I really want to do this, and I really need the money," she exclaimed, "but I just got my period this morning and I am in absolute agony with cramps. What can I do?"
It did not take long to come up with an answer. "Instead of researching 'sex', we'll research 'dysmenorrhea' today", I replied. It is actually a rare opportunity to get research subjects when they are in great pain -- they usually call up and cancel.
Insertion of the vaginal EMG sensor required removal of her tampon, with predictable consequences. But replacement of the bed sheets and blanket was a small price to pay for the valuable data we collected that day.
1.
Initially, the subject was simply unable to make any recognizable
"Kegel" type contraction, as shown in the figure on the right.
In the bottom margin the square tracing below the hand-written numbers shows the
condition of the signally light -- up or down indicates instructions of
"contract" and "relax" respectively.
Two aspects of the tracing are noteworthy. First, the general trend is one of gradual increasing pelvic floor EMG, starting with a 10-second interval average of 13.3 microvolts and increasing to over 25 microvolts -- about double. There is no relationship between her efforts to contract and the activity of her muscles -- they are completely out of control. Second, there are many strong spikes that rise to the mechanical top of the chart (a tad above the topmost horizontal line). These "spikes" represent involuntary spasms or "cramps" of the pelvic muscle, and they are very numerous. Both the chronic tension (the general trend line) and the spasms (the spikes) were perceived by the patient as "painful".
This tracing confirmed what we had long suspected -- in dysmenorrhea the muscles are simply out of control and in constant spasm. Although the degeneration of the uterine lining causes some initial discomfort, it is the over-activity of the pelvic muscles that is the major source of debilitating pain. (Which, in turn, is a major factor in employee health costs.)
Kegel exercises (and sexual orgasm) are often recommended by experts as ways to alleviate cramps. I began by asking the subject how she knew if she was doing a pelvic muscle contraction. "Oh," she said, "that's easy. I can tell by looking at my belly!" Needless to say, she was quite wrong about how her muscles functioned. In fact, there is a statistical tendency for her muscles to be doing the opposite of what she intend in the above chart.
I instructed her to observe instead the light-bar display on a Cyborg P-303 EMG biofeedback instrument, and told her that any increase in the number of LEDs indicated a stronger contraction. She practiced making contractions and relaxing with continuous encouragement and improvement over the course of 60 minutes. Suddenly, over the intercom, she announced: "Hey! My cramps are all gone!"
2. And, indeed, so were most of the spikes, and her overall muscle patterns had
begun to resemble a normal "Kegel" pattern, as shown on the
left. Now her resting levels were in the 4 to 6 microvolt range, and her
attempted contractions were in the range of 9 to 12 microvolts. Notice
especially that her "relaxations" are relatively flat, while her
attempted contractions are quite irregular. In addition, her overall
"strength" was only low average for her age and physical condition.
Since her chronic tension had registered much higher, I suspected she was still
having trouble recruiting muscle fibers effectively. So in spite of resolving
her "cramps", I decided to continue the EMG biofeedback training for a
few more minutes.
3. At 75 minutes into the training, her muscle contractions become much
stronger, averaging about 25 microvolts again, while her relaxation trials were
sometimes lower. She was, however, beginning to show signs of fatigue in
her contractions, so I decided to end the session. This subject had been
my first "dysmenorrhea" patient. Now, with over twenty years
additional experience with pelvic muscle EMG, I surely would have invited her to
return for a second training session a week later.
The student was seen regularly (in classes) for six additional months until she graduated from college. During this time she continued to report the absence of any debilitating cramps associated with her periods. She especially like getting paid for the "treatment"!
At least a dozen other patients and research subjects have since been given the opportunity to learn proper contraction and relaxation of the pelvic muscles during a dysmenorrhea attack, and all have reported the total elimination of disabling cramps as a result. The key to success, however, seems to be learning the new behavior while the cramps are at their worst. It may be that the contrast between the initial painful condition and the relaxed result strongly reinforces the lesson.
This was the first of many pain patients who contributed to the formation of the "Sensation-Perception Theory" of certain muscular pains. The contributing patients eventually included those with a variety of lower back pain, tennis elbow, tension headache problems, and other conditions as well.
The best explanation for pain patients who have an overlay of chronic muscle tension, including spasms or cramps, is that the effective cause is an attempt to deny awareness of an underlying original pain, such as an injury, scar tissue, or similar cause.
"Sensation" involves, in psychophysiological terms, "mere" conscious awareness of a pain (or, for that matter, of a pleasurable stimulus as well). "Perception", on the other hand, is a complex cognitive process by which the brain tries to "understand" what is being sensed. It involves "interpretation" of the sensation. When you touch a hot stove, a reflex causes an almost immediate reaction to the sensation; only later do you "explain" to yourself what happened.
Unfortunately, perceptions often get out of hand; the lump in my skin may be an incipient cancer, the pain in my uterus may signal a ruined "date" on Saturday night, etc. One ineffective way to cope with pain is to try to deny it is even there to start with. Through mechanisms well known to physiophysiologists, we can simply "turn off" awareness of irritating sensations, blocking them completely from conscious awareness.
But when we turn off awareness of our normal muscular sensations, the muscles begin to get out of control. Eventually they begin to fibrillate or go into spasm, much like the children in the school cafeteria when the adult monitor is no longer watching them. The more and longer they contract, the more the pain, the more the denying person tries to pretend they don't feel anything. It is a vicious cycle that can only be broken by restoring sensation. The patient has to acknowledge the underlying sensation, while neither getting overly concerned or pretending it isn't there. It should be obvious that a bit of Zen philosophy would reinforce the concept involved here.
In order to "do" Kegel exercises, the patient has to restore mental awareness of the normal sensations of the muscles contracting and relaxing. In the process, the patient "regains control" over the offending muscles, and they begin to assume normal relaxed patterns. This process can be explained at a much more technical level, but such an explanation is not required to effectively use the technique.
PS: Thanks, S., where ever you are! You probably never knew how much you taught me, or how many other women you helped that Saturday morning in April, 1979
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Copyright 2001 by John D. Perry, PhD. All rights reserved.
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