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The initial session at the Cleveland Clinic-Florida begins with a thorough history intake. The learning process begins with a description of the anatomy and physiology of the bowel and pelvic muscle function using anatomic diagrams

Figure 13.11. Channel 1: sEMG tracing of the PFM during a Valsalva maneuver. Note the increase muscle activity indicative of a paradoxical contraction. Channel 2: Abdominal sEMG tracing.

and visual aids. Verbal and written instructions are simplified for easy comprehension using layman's terminology. This is followed by a description of the biofeedback process, instrumentation, and PMR exercises. Patients should be aware that physicians cannot make muscles stronger or change muscle behavior. However, patients can learn to improve symptoms and quality of life by active participation and commitment to making changes. Results are not immediate; as with any exercise program, muscle improvement requires time and effort. Beginning goals of isolated pelvic muscle contractions are established and an example of sEMG tracing showing efficient muscle function is reviewed. Patients are given instructions on proper insertion of the internal sensor and remain fully clothed during the session. They are placed in a comfortable semi-recumbent position for training; however, internal sensors work in a variety of positions for functional maneuvers such as standing while reviewing urge suppression or sitting while performing the Valsalva maneuver. Surface electrodes are then placed on the right abdominal quadrant along the long axis of the oblique muscles, below the umbilicus used to monitor abdominal accessory muscle use. The cables are attached to the SRS Orion PC/12 (SRS Medical Systems, Inc., Redmond, WA) multi-modality instrumentation that provides the ability to simultaneously monitor up to four muscle sites (Fig. 13.3). The EMG specifications include a bandwidth of 20 to 500 Hz and a 50/60-Hz notch filter. The sEMG evaluation is performed and reviewed with the patient.

Training for dyssynergia, incontinence, or pain begins with the systematic shaping of isolated pelvic muscle contractions. Observation of other accessory muscle use such as the gluteal or thighs during the session is discussed with the patient. Excessive pelvic muscle activity with an elevated resting tone >2 ||V may be associated

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Figure 13.12. Channel 1: PFM sEMG tracing indicative of poor muscle function as seen with the slow recruitment, inability to maintain the contraction along with the recruitment of abdominal muscles seen in channel 2.

with dyssynergia, voiding dysfunction, and pelvic pain. Jacobson's progressive muscle relaxation strategy indicated that after a muscle tenses, it automatically relaxes more deeply when released.21 This strategy is used to assist with hypertonia, placing emphasis on awareness of decreased muscle activity viewed on the screen as the PFM becomes more relaxed. This repetitive contract-relax sequence of isolated pelvic muscle contractions also facilitates discrimination between muscle tension and muscle relaxation. Some patients, usually women, have a greater PFM descent with straining during defecation associated with difficulty in rectal expulsion. Pelvic floor weakness may result in intrarectal mucosal intussusception or rectal prolapse, which contributes to symptoms of constipation. Furthermore, the PFM may not have the ability to provide the resistance necessary for extrusion of solid stool through the anal canal.16

Multifactorial concomitant PFM dysfunction accounts for the rationale to initiate all patients with isolated pelvic muscle rehabilitative exercises. Home practice recommendations depend on the observed decay in the duration of the contraction accompanied by the abdominal muscle recruitment (Fig. 13.12). The number of contractions the patient is able to perform before notable muscle fatigue occurs gauges the number of repetitions recommended at one time. Fatigue can be observed in as few as three to four contractions seen in patients with weak pelvic floor muscles. As an example of home practice, the patient performs an isolated pelvic floor muscle contraction, holds for a 5-second duration, relaxes for 10 seconds, and repeats three to 10 times (one set). One set is performed three to five times daily, at designated intervals, allowing for extended rest periods between sets. The lower the number of repetitions, the more frequently interval sets should be performed daily. Excessive repetitions may overly fatigue the muscle and exacerbate symptoms. If patients are unable to perform an isolated contraction on the initial evaluation, they are given instructions for the Beyond Kegel exercises. The goal for patients is to be able to perform isolated pelvic muscle contractions alternating with the Beyond Kegel exercises, to ultimately achieve efficient PFM function. All patients are requested to keep a daily diary of bowel habits, laxative, enema or suppository use, fluid intake, number of home exercises completed, fiber intake, and any associated symptoms of constipation or incontinence.

Subsequent sessions begin with a diary review and establishing further goals aimed toward individualized symptom improvement. This is followed by an sEMG evaluation, which may include the addition of quick contract and release repetitions, Valsalva maneuver, or Beyond Kegel exercises depending on the patient's progress. These objective measurements gauge improvements in muscle activity that should be seen with each visit and occur prior to symptomatic improvement; this provides positive reinforcement for the patient to continue treatment. To assist with compliance, additional tasks should be limited to no more than three at any given time. These tasks, tailored to the individual needs, may include increasing the duration and number of PFM exercises, alternating Beyond Kegel exercises, habit training, physiologic quieting, anorectal coordination maneuvers, increasing fiber and fluid intake, increasing activity, or modifying laxative use or other methods of evacuatory assistance. Although the ideal goal may be to abolish all symptoms, this may not always be accomplished due to underlying conditions; however, individual goals are important, and some patients may be satisfied simply with the ability to leave home without fear of a significant fecal accident. Improved quality of life and patient satisfaction should be considered a treatment success.

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