The Role of Home Trainers in Kegel's Exercise Program for the Treatment of Incontinence by John D. Perry, PhD and Leslie Talcott Hullett, MS, RN
from Ostomy/Wound Management, The Journal for Extended Patient Care Management, Volume 30, September/October 1990
Reprinted by permission from Ostomy/Wound Management. Copyright 1990 by Health Management Publications, Inc.
In the past decade, many studies have demonstrated the effectiveness of biofeedback-assisted Kegel exercises in the treatment or even cure of fecal incontinence. The earliest of these studies were based on the use of anorectal manometry, a mechanical pressure transducer system, to treat fecal incontinence. Recently, Burgio, have shown that the same techniques can be applied to the treatment of urinary incontinence with an average of 85% reduction in frequency of accidents (40% actually cured). In another study, biofeedback from a polygraph chart was found to be superior to mere verbal feedback from a therapist (76% improvement vs. only 51%). All of these studies were conducted at the National Institute on Aging laboratories in Baltimore, using an ano-rectal manometer, a complex polygraph laboratory instrument, and all of them reference the original Kegel exercise program as their primary model and inspiration.
These NIA-sponsored reports and their projects differ in several important aspects from the original research that they emulate. First and most significantly, they obtain considerably poorer results than those reported by Arnold Kegel. In an important 1950 chapter,6 Kegel claimed "complete relief of urinary stress incontinence" in 93% of some 300 patients treated with his perineometer device. He also observed that "preliminary returns of a statistical inquiry among private physicians using the perineometer" yielded a comparable figure of 91%.
The NIA-sponsored research also reports percentages in the 80s and 90s, but it is necessary to note that the data always represent an "average reduction in symptoms (accidents)" across all subjects; the percentage of patients actually "cured," or obtaining Kegel's "complete relief," is only 29% (weighted across all studies), significantly less than the research they are duplicating. Some critics have suggested in private that Kegel may have exaggerated his figures; however, we have found no evidence concerning that charge. A closer examination of the other differences offers a more plausible and less sinister explanation. The clue to the differences in results may be found in differences in philosophy and implementation. The NIA research differs from Kegel's in terms of l) the type of instrumentation, 2) the basic orientation (home vs. office), and 3) the patient work requirements.
Kegel's Perineometer in use. Thrice daily home practice sessions with this biofeedback device were the basis for Kegel's exercise program. © 1952 Ciba-Geigy Corporation. Reproduced with permission from Clinical Symposia by Frank H. Netter, MD. All rights Reserved.
The primary instrumentation involved in Kegel's exercise program was a home training device, the Kegel Perineometer, which each patient was required to obtain and use at home in three daily practice sessions. The device consisted of a small rubber cone that was inserted into the --- entrance, a length of rubber tubing, and a 2-inch diameter manometer (air pressure gauge) calibrated in millimeters of Mercury. Contractions of the pelvic muscles around the --- depressed the walls of the cone and this activity was conveyed to and displayed on the hand-held gauge (see Figure 1). Because the cone was sensitive to insertion pressure as well, it was typically held in place by a band of gauze so as to avoid movement artifact.
The patient was introduced to the perineometer in the physician's office, and her first practice sessions were conducted in his presence so that he could ensure that the patient would be practicing correctly at home. Kegel even created and furnished an apparently effective self-charting progress report form that antedates techniques used in Behavior Modification programs by over 20 years. We shall refer to the office monitoring of home practice as the "Kegel Method." (See Figure 2)
Figure 2: The Home Practice Chart distributed with Kegel's 1948 Perineometer. Patients were expected to practice three times a day, starting at five minutes per session and increasing to 20 minutes per session during the fourth week.
In 1985, the National Institute on Aging produced a documentary videotape that summarized the biofeedback and behavioral techniques that had been developed in their physiology laboratory.[7] The film was intended to provide instruction for non-physicians in the NIA's treatment method. Like the Kegel Method, this "NIA Method" involves the use of biofeedback, but only in the laboratory, not at home. The limitation apparently stems from the use of manometric instrumentation; the sensor is a series of balloons mounted on a shaft, which must be carefully inserted several inches into the rectum under direction of a physician. The balloons are connected by several pieces of tubing to a bank of mechanical to electrical transducers, which are in turn connected to a laboratory polygraph or multi-channel strip chart recorder. The patient, who must remain in the lithotomy position, watches the strip chart output, sometimes with the aid of an opaque projector. The apparatus costs about $25,000 and requires a medical laboratory environment.
The rectal insertion is quite uncomfortable for the patient. In general, most patients endure the treatment only three or four sessions. In addition, when the patient is being treated for urge incontinence, the bladder is infused with sterile water through a catheter for direct feedback of bladder contractions; and 2 or 3% of these infusions result in bladder infections. In three or four laboratory biofeedback sessions, the patient must learn as much as possible about his or her internal muscles. Patients are, of course, encouraged to practice the same exercises on a daily basis at home.
Kegel's patients practiced between 90 and 360 sessions with the biofeedback device (for one to four months participation, respectively), whereas the NIA patients had only 1 to 5 biofeedback sessions all together. This represents the third major difference between these two approaches: the amount of exercise prescribed for the patient. Kegel recommended 300 instrumented contractions per day for therapy. These were to be supplemented by 150 non-instrumented contractions per day after the therapy was well established and were to continue throughout life. In contrast, the NIA protocol uses only one-sixth as much practice, 51 per day in the urinary incontinence research; all of them are done without instrumentation.
The rationale for the drastic reduction in exercise requirements has never been described in the literature but may be related to the nature of participation. All of Kegel's subjects were patients who were paying for their therapy, whereas all of the NIA subjects were receiving "free experimental" therapy in a government-sponsored research program. This may have affected the level of expected commitment in the later group. The greater amount of exercise prescribed may account for the better results obtained by Kegel. Only one study has compared exercise levels; Rudinger showed that a group doing 300 contractions per day did considerably better than a control group doing only 100 contractions per day.
One element both programs have in common is their use of air pressure operated sensors to infer muscle activity on the basis of physical displacement of the --- or rectal space. Beginning in the 1970s, however, researchers have been making direct muscle assessments through newly developed electromyographic (EMG) amplifiers and feedback systems. These have the advantage of being considerably more sensitive than manometric devices; they are capable of detecting muscle activity at trace level. At first, external "patch" electrodes were used; but in 1975, rectal electrode assembly, the
EMG Perineometer, was introduced, allowing more accurate detection of pelvic floor muscles. In 1982, a portable home trainer, the
Personal Perineometer⢠was designed for use with it.
Figure 3 A contemporary EMG home trainer.
The home trainer was followed in 1983 by an office instrument, the Clinical Perineometerâ¢, which performs some of the same functions as the polygraph, but in a transportable table-top instrument. The new system combines the office instrumentation of the NIA method with the portable home trainers used by Arnold Kegel. The first project to use this new system was sponsored by the New Jersey Department of Health; nurse practitioners obtained a 78% symptom reduction rate among 54 seniors at a walk-in health facility.[9] Most of the participants used the Personal Perineometer home trainer but usually only for the first one or two weeks. Although only 37% were "cured" at the end of treatment, this number actually increased to 59% cured after an additional year of unsupervised practice. In a related project, using the same Clinical Perineometer but without the home trainers, a group of 25 home-bound seniors obtained an overall 70% reduction in accidents.
