Lessening the Burden

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December 2003

By Amy U. Altman, MPT

The use of biofeedback with exercise can greatly reduce urinary incontinence.

Have you ever had the misfortune of experiencing urine loss while in a public place? Couldn’t make it to the bathroom in time? Laughed or coughed too hard? How did it make you feel? Thirteen million Americans, 38% of females and 19% of males, are plagued by urinary incontinence.¹ Studies show prevalence ranges from 1.5% to 5% in the male population ages 15-64, and 10% to 30% in women of the same age.^2,3

Although such a large proportion of the population experiences urinary incontinence, the majority of those individuals do not seek care. Due to the sensitive nature and social stigma associated with this disorder, patients are often embarrassed to discuss the condition with their physician. Surveys have indicated that less than half of the comm-unity-dwelling population with incontinence seeks treatment for their symptoms.⁴ As the Agency for Health Care Policy and Research (AHCPR, now the Agency for Healthcare Research and Quality) guidelines for urinary incontinence suggest, prevalence of incontinence does increase with age, but should not be considered a normal part of aging.⁵

Although studies show women are unaware of the current treatments for incontinence or assume treatment is ineffective,⁶ the AHCPR guidelines suggest that treatment of urinary incontinence is effective in most people.⁵ The goal of this article is to highlight the role of biofeedback in pelvic muscle exercise as a safe and effective treatment for urinary incontinence.

Types of incontinence

There are several types of urinary incontinence with stress, urge, and mixed urinary incontinence most prominent. Stress incontinence consists of urine leakage with increased intra-abdominal pressure. Increased pressure in the abdominal cavity pushes down on the bladder. When pressure in the bladder exceeds urethral pressure, urine is lost unless the bladder outlet is adequately closed to prevent leakage.⁷ Increases in intra-abdominal pressure may occur with laughing, coughing, or sneezing, or during physical exertion such as bending, lifting, or exercise. Although urine loss is typically small, the amount of leakage depends on the degree of exertion.⁷ With strenuous activities such as exercise or heavy lifting, urine loss may be large enough to soak the outer clothes. In women, stress incontinence is commonly associated with multiple vaginal births, incontinence surgical procedures, decreased estrogen levels associated with menopause or hysterectomy, and aging.^8,9

Figure 1. EMG display of normal 1-second pelvic floor contraction, 6 repetitions. Recorded with vaginal sensor.

Figure 2. Poor recruitment of 1-second pelvic floor contractions in a patient with stress incontinence.

Urge incontinence is defined as the involuntary loss of urine associated with a strong desire to void.⁵ When bladder fullness is perceived, an individual senses a sudden urge to urinate and is unable to delay voiding. Urine loss is typically moderate to large and often occurs on the way to the bathroom. An involuntary contraction of the bladder detrusor muscle occurs prematurely during filling and forces urine through the urethra.⁷ An individual with urge incontinence is unable to inhibit this contraction or close the urethra adequately and urine leakage results.

Often, voiding frequency is increased in an effort to keep the bladder empty and avoid the sudden urge to urinate. Urge incontinence predominately occurs in older adults. Presence of both urge and stress incontinence is classified as mixed incontinence and occurs in 40% of incontinent people.⁷

Effects of exercise

The AHCPR advocates selection of the least invasive treatment with the fewest potential adverse effects as a first course of treatment of urinary incontinence.⁵ For many types of urinary incontinence, behavioral techniques meet these criteria. Suggested behavioral techniques include toilet assistance, bladder retraining, and pelvic muscle exercise with or without augmentation by biofeedback, electric stimulation, or vaginal weight training. Behavioral techniques are most effective with motivated patients who wish to avoid protective garments, medication, or surgical intervention.⁵

Pelvic muscle exercises began in 1948 when Dr Arnold Kegel developed a program of progressive pelvic floor contractions in combination with biofeedback training to treat women with urinary incontinence. Various researchers over the past 50 years have implemented their own exercise protocols, but the exercise itself has remained the same. The goal of pelvic muscle exercise is to isolate and strengthen the pelvic floor, or levator ani musculature. Often patients do not know how to squeeze the pelvic floor appropriately without substitution or accessory muscle use.

The pelvic floor muscles are a group of muscles that attach to the base of the bony pelvis and provide support to the pelvic organs and control of the outlets. Quality of support depends on anatomical position, resting tone, volume or cross-sectional area of musculature, and integrity of the fascia.¹⁰

The pelvic floor is composed of two types of muscle fibers, 30% fast-twitch and 70% slow-twitch fibers.¹¹ At rest, slow-twitch fibers are activated tonically to provide support to pelvic viscera. These fibers are primarily responsible for setting the resting tone. Pelvic floor muscle tone may vary with hormonal status such as during menstrual cycle, pregnancy, and menopause and can be influenced by the lumbar and pelvic musculoskeletal system.¹² Resting tone may be classified as hypotonic, normal, or hypertonic. Typically, persons experiencing incontinence have hypotonicity, or underactive muscle tone, which indicates insufficient functional activity of the pelvic floor muscles.¹²

Fast-twitch fibers are activated during increases in intra-abdominal pressure in an effort to quickly close the urethra and provide greater resistance in anticipation of increased pressure from the bladder.¹² With contraction, the urethra, vagina, and rectum are compressed and pelvic organ displacement is prevented. Contracting the pelvic floor enhances closure of the urethra. With this closure, pressure in the urethra is elevated and leakage is avoided. Contraction also helps to maintain urethral position during increases in intra-abdominal pressure.¹³ If patients can perform the contraction prior to activities that raise intra-abdominal pressure, stress incontinence can be avoided. Pelvic floor contraction can also reflexively inhibit the detrusor muscle, which may help to lessen the incidence of urge incontinent episodes.

Bringing in biofeedback

Biofeedback is a device that records electromyographic (EMG) information of the pelvic floor utilizing either surface electrodes or a vaginal or rectal probe. Biofeedback teaches the patient how to improve control of the external sphincter by contracting the pelvic floor muscles.⁷ Visual and auditory stimuli such as graphs, color, and sound provide information or feedback regarding the patient’s performance. The feedback is used to alter the patient’s neuromuscular control of the pelvic floor. A trained clinician continually monitors the patient’s performance and provides verbal cues to enhance performance. With constant knowledge of performance, the patient is encouraged to make small changes in order to increase motor control of the pelvic floor muscles. Biofeedback training is most appropriate for the patient who is cognitively intact with neurologically intact musculature and is motivated to comply with the program.⁵

The biofeedback instrument displays myoelectric signals of the pelvic floor muscles in a graphic form with optional color and auditory capabilities. A system with two or more channels is preferable, in order to monitor the activity of potential compensatory muscle groups such as the abdominals or gluteals. The EMG graph displays data such as resting tone, strength, endurance, and temporal characteristics. Resting tone is the amount of tension that resides in the musculature when the muscle is inactive. Strength is recorded by the maximum pressure or the peak of the waveform. Endurance is the average muscle contraction measured across the waveform.¹¹ Endurance can be measured by period of time a contraction is sustained or maximum number of repetitions that can be performed.¹² Temporal characteristics include contractibility or rate of the rise of the contraction, and time to release. The EMG signal of the second channel monitors the accessory muscle activity and should remain quiet with little activity.

Biofeedback provides visual and/or auditory stimuli to facilitate motor learning. With a visual image of muscle activity on the display and verbal cueing, the patient is assisted in identifying a correct pelvic floor contraction. Once the contraction is isolated consistently, an individualized exercise program is developed. The therapist utilizes basic exercise and motor learning principles to facilitate neuromuscular re-education.

Principles used in general strength training can be applied to pelvic muscle exercise. The principles include specificity of training, overload, and reversibility.¹¹ Training effects are highly specific to the methods employed, therefore, an exercise program should include training of both fast- and slow-twitch muscle fibers. Fast-twitch fibers are trained with quick burst-like contractions, while slow-twitch fibers are targeted with less intense endurance contractions of longer duration. Overload principles suggest a muscle must be continually worked beyond its normal limit to gain strength. An exercise program must be continually modified in order to account for improvements in strength and endurance. The principle of reversibility applies to the muscle’s ability to return to its prior level of function with cessation of exercise. Patients must continue the prescribed program in order to maintain the desired effect.

Principles of motor learning are helpful when re-educating the pelvic floor muscles. When instructed to contract the pelvic floor, many individuals also recruit the abdominal, gluteal, or thigh muscles. Motor learning theory indicates that when learning a new task, an individual recruits assistance from surrounding musculature. As the skill acquisition proceeds, the individual is able to free accessory muscles and perform a more fine-tuned movement with less effort.

During an initial biofeedback training session, the focus is to increase the patient’s awareness of pelvic muscle activity and inhibition of accessory muscle use. The patient practices the skill while utilizing visual information and verbal cueing from the therapist. Verbal cueing decreases as proficiency of the task increases. Biofeedback training provides constant knowledge of performance via visual and verbal feedback, therefore, acquisition of the skill is accelerated.

If the patient is having difficulty with voluntary contraction or isolation of the pelvic muscles, electrical stimulation may be an appropriate adjunct to training. It also can be used to inhibit involuntary detrusor contractions as seen with urge incontinence.

Electrical stimulation provides contraction of the pelvic muscles with an external device. The patient is instructed to squeeze as the stimulator elicits contraction of the pelvic muscles. Repeated contraction can heighten a patient’s awareness of contractility and increase strength and recruitment.

Personal treatment

Exercise prescription for pelvic muscle exercises should be individually tailored for the patient. Once the patient has demonstrated the ability to isolate pelvic floor contraction in the supine position, training progresses to the seated and standing positions. Each successive position provides additional demands on the pelvic muscles. For example, the effect of gravity introduces variables such as body weight, active muscle recruitment to maintain posture, fascial and ligamentous support, and pelvic organ position. The training program must also address the specific functional needs of the patient. If leakage occurs when lifting a patient’s 10-pound infant, training should simulate this activity. The therapist is limited only by his or her own creativity when it comes to functional training.

No matter how productive a training session may seem, if the patient is not compliant with his or her home exercise program, no improvement in muscle strength, coordination, or symptoms will result. It is the therapist’s responsibility to collaborate with the patient to develop an exercise program that fosters adherence.¹⁴ The therapist determines the appropriate exercise parameters, but should consider the context of the patient such as work schedule, familial duties, community responsibilities, etc. Establishing specific exercise times such as during daily commutes to and from work, and at lunch break may be easier to integrate, rather than instructing your new patient to exercise her pelvic floor five times per day for the rest of her life. If the patient is an active part of the process, he or she will be more likely to be compliant.

Biofeedback serves as an effective training tool that provides patients with the knowledge and skills to successfully exercise the pelvic muscles and manage their urinary incontinence symptoms. Medical management of this disorder is limited by the incontinent patient’s hesitancy to seek care. Guidelines have been established by the AHCPR in an attempt to educate health care providers and advance the timely diagnosis and treatment of urinary incontinence. It is our responsibility as health care professionals to increase public awareness in order to encourage individuals to seek treatment and reduce the psychosocial and economic costs of this manageable disorder.

Amy U. Altman, MPT, is a physical therapist specializing in women’s health at Body Rebuilders Physical Therapy, an outpatient clinic in Bala Cynwyd, Pa.

References

National Kidney and Urologic Diseases Advisory Board. Barriers to Rehabilitation of Persons with End-stage Renal Disease or Chronic Urinary Incontinence. Workshop summary report; March 7-9, 1994; Bethesda, Md.
Burgio KL, Matthews KA, Engel BT. Prevalence, incidence and correlates of urinary incontinence in healthy, middle-aged women. J Urol. 1991;146:1255-1259.
Harrison GL, Memel DS. Urinary incontinence in women: its prevalence and its management in a health promotion clinic. Br J Gen Pract. 1994;44:149-152.
Burgio KL, Ives DG, Locher JL, Arena VC. Treatment seeking for urinary incontinence in adults. J Am Geriatr Soc. 1994;42:208-212.
Urinary Incontinence Guideline Panel. Urinary Incontinence in Adults: Clinical Practice Guideline. Rockville, Md: Public Health Service; 1992. Agency for Health Care Policy and Research, Public Health Service, US Dept of Health and Human Services. AHCPR Publication No. 92-0038.
Branch LG, Walker LA, Wetle TT, DuBeau CE, Resnick NM. Urinary incontinence knowledge among community-dwelling people 65 years of age and older. J Am Geriatr Soc. 1994;42:1257-1262.
Newman DK. Managing and Treating Urinary Incontinence. Baltimore: Health Professions Press; 2002:36-40,123-130.
Robinson D, Cardozo LD. The role of estrogens in female lower urinary tract dysfunction. J Urol. 2003;62(Suppl 1):45-51.
Parazzini F, Chiaffarino F, Lavezzari M, Giambanco V; VIVA Study Group. Risk factors for stress, urge or mixed urinary incontinence in Italy. BJOG. 2003;110:927-933.
Olsen AL, Smith VJ, Bergstrom JO, Colling JE, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89:501-506.
Laycock J. Pelvic muscle exercise: physiotherapy for the pelvic floor. Urol Nurs. 1994;14:136-140.
ICS Pelvic Floor Clinical Assessment Group. Terminology of Pelvic Floor Function and Dysfunction. March 2002.
McIntosh LJ, Frahm JD, Mallet VT, Richardson DA. Pelvic floor rehabilitation in the treatment of incontinence. J Reprod Med. 1993;38:662-665.
Jensen GM, Lorish C, Shepard KF. Understanding patient receptivity to change: teaching for treatment adherence. In: Shepard KF, Jensen GM, eds. Handbook of Teaching for Physical Therapists. Newton, Mass: Butterworth-Heinemann; 1997:241-270.

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December 2003