In the late 1940s, Arnold Kegel17 developed a vaginal balloon perineometer to teach pelvic muscle exercises for poor tone and function of the genital muscles. He was instrumental in developing a standardized program for treating urinary stress incontinence. Kegel's program included evaluation and training utilizing visual feedback for patients to receive positive reinforcement as they monitored improvements in the pressure readings. Kegel also recommended structured home practice with the perineometer along with symptom diaries. His clinical use of these techniques showed that muscle reeducation and resistive exercises guided by sight sense are a simple and practical means of restoring tone and function of the pelvic musculature.17
Unfortunately, clinicians taught Kegel exercises without the use of instrumentation. Bump et al18 showed that verbal or written instructions alone are not adequate, concluding that 50% of patients performed Kegel exercises incorrectly. There are disadvantages to teaching Kegel exercises without specific feedback from muscle contractions. There is a strong tendency to substitute abdominal and gluteal contractions for weak pelvic floor muscles. This incorrect manner of performing Kegel exercises is reinforced by sensory proprioceptive sensations, giving faulty feedback for the desired contraction, and, in effect, rendering the Kegel exercise useless.9 For patients with fecal or urinary incontinence, abdominal contractions raise intraabdominal pressure, thereby increasing the probability of an accident. For patients to begin performing isolated pelvic muscle contractions, they are instructed to contract their pelvic floor muscles without contracting abdominal, gluteal, or leg muscles, and to hold this contraction to the best of their ability. This is done while using the instrumentation display of the simultaneous sEMG activity of the abdominal and pelvic floor muscles for feedback. The patient must tighten the pelvic diaphragm (levator ani) in a manner similar to stopping the passage of gas or the flow of urine. Patients should be advised that the initial aim of treatment is not to produce a contraction of maximum amplitude, but to contract the pelvic floor muscle in isolation from other muscles without undue effort. To build muscle endurance, training proceeds with gradual increases in the duration of each contraction along with gradual increases in the number of repetitions. Rhythmic breathing patterns during contractions should be encouraged.
Recommended home practice is tailored according to the patient's ability and the degree of muscle fatigue observed during the session.
Figure 13.10. Beyond Kegel adductor assist resistive exercise.
At each stage of treatment, patients are encouraged to practice these exercises daily without instrumentation feedback. While Kegel17 asked patients to perform approximately 300 contractions daily during treatment and 100 during maintenance, there is no known optimal specific number of exercise sets. The goal of Kegel exercises is to facilitate rehabilitation of the pelvic floor muscles to achieve efficient muscle function. This includes normal resting tone, rapid recruitment of the pelvic floor muscles, sustained isolated pelvic muscle contraction, quick release to a normalized resting tone, and appropriate relaxation during defecation or micturation.
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