Biofeedback Assisted Pelvic Floor Muscle Training - Diane Newman

July 17, 2023

Diane Newman shares her extensive knowledge about biofeedback-assisted pelvic floor muscle training. She traces her introduction to biofeedback in the late 1980s, and its subsequent use in managing urinary and fecal incontinence, detailing its evolution to the more user-friendly Prometheus Group biofeedback equipment she currently employs. Newman praises the innovative features of the equipment, such as visual indicators like a blooming rose that represents muscle contractions and relaxations. Biofeedback, she explains, is a non-invasive treatment that helps patients identify and strengthen pelvic floor muscles to mitigate conditions like urinary incontinence, bladder urgency, and frequency. She illustrates her process using electro-myography (EMG) to measure muscular electrical activity, demonstrating notable patient progress over four weeks. Newman cautions that seeing results might take up to three to six months, but reassures that patience and persistence are keys to success. She concludes by affirming the transformative impact biofeedback can have on patients' lives.


Diane K. Newman, DNP, ANP-BC, BCB-PMD, FAAN, Adjunct Professor of Urology in Surgery, Research Investigator Senior, Perelman School of Medicine, University of Pennsylvania, and Former Co-Director of the Penn Center for Continence and Pelvic Health, Philadelphia, PA

Read the Full Video Transcript

Diane Newman: So now we're going to talk about biofeedback assisted pelvic field muscle training.

I've been doing biofeedback interventions, really, oh, last 35 years, since late 1980s. I learned how to do biofeedback by Kathy Burgio, who was a behavioral scientist at the Geriatric Research Center, which is in Baltimore. It's part of the NIH. She was doing biofeedback with a researcher, Bernie Engel, on fecal incontinence. And the biofeedback back then was inserting catheters in every orifice, rectum, the vagina in women, in the bladder, and showing them the bladder pressure, the pelvic floor muscle contraction on this very sophisticated, confusing, I thought, graph. But I learned what to do and I saw the effectiveness. And there's a lot of research that came out in that time period on urinary and fecal incontinence that showed that it worked.

Since the early '90s, I have used the Prometheus Group biofeedback equipment. I have found this to be the user-friendly. I'm not a clinician that wants to spend all my time on the equipment, how to figure it out, how to start it. It's a tool for me that I need in my exam room, in my treatment room, similar to what a primary care physician or nurse practitioner or PA would use a stethoscope, my biofeedback equipment is what I need. I have found that patients love it when they can visualize their contraction. With this equipment I can show a graph that's in color, I can use games and one of the newest things that he has developed, the company's developed for me and for other clinicians, is a rose, the actual flower rose that opens up and closes depending on contraction and relaxation. So it's very visual, and I think it's important.

Many patients will say to me after we do a session, "Oh, Diane, can I take this program home with me? Can I load it on my phone?" Because they finally did so helpful for doing these exercises. And now what's exciting is that most insurers will cover it and there's codes for biofeedback and Medicare also has just changed your coding, so it's very positive.

So let's go over biofeedback assisted pelvic floor training. I have published many, many articles. You'll find my CV on the website. Please look for any of my publications and get them. I did one specifically just a couple years ago on pelvic floor muscle rehabilitation using biofeedback. So what do I use in my practice? I also did an article on office-based behavioral therapy with Dr. Alan Wein, who's chair of Penn Neurology at the University of Pennsylvania, who's been one of my biggest supporters. He really believes in, this sends me every patient that has any type of void dysfunction because he knows how effective. So if you need more information that's out there in print, please get it.

So what is biofeedback? It's painless treatment that helps a person identify and strengthen the pelvic four muscles. It helps the person locate the correct muscle, because if they're not contracting the correct muscle, you're not going to see either a gain or butterflies flying up into the sky or the graph increase. And it also can be used to prevent bladder leaks, urinary incontinence, bladder or bio-urgency and frequency. It's been shown to help 8 out of 10 individuals. So also what biofeedback can do, it shows them how the muscle can change. So how long can they keep the contraction or the squeeze? All right. And also they can learn how to use this muscle. And it uses a computer, so it's computer driven.

Now if you look back in the literature, Dr. Kegel, who was the first one that described the isometric contraction of pelvic floor muscle that became a Kegel exercise, really had a biofeedback device. He developed something called a perineometer. And the saying is that he did it in his garage with a tire gauge. And as you can see on this picture, it was a manometric device, which means it measured pressure, the pressure of the pelvic floor muscle contraction, and that went in the woman's vagina. And then as she squeezed, the tire gauge increased in numbers.

And what else he had that I think is very important if you read his literature, is that he had a specific center or clinic that treated these women and he had a nurse, a specialized nurse. And that is really what I have done, my practice is, I'm specialized in this, I am biofeedback certified and I have my practice and I use a device. So that's what he did in the 1940s, so we're talking over, what? 70 years ago. And what happened in the interim is the woman was just given instructions on it without really a very intensive program. And the data now is showing that an intensive program by a trained clinician is the most effective.

This is my setup. This is a setup that you can use. And basically you can see that I have the equipment, Prometheus Group's equipment on the little carts which I run and I look at and the patients on the exam table, and they're viewing the monitor so they can watch and they visualize a biofeedback while I control from the computer's console.

I use EMG, and that's basically shows the contraction of the skeletal muscle. So it's electrical contractions, they contract, and it's not a measure of force, it's a measure of electrical activity. You can see on this picture that the one on the left is an old piece of equipment I had, so I've been using it for years. This is the neuro one, the patient's sitting there and viewing the biofeedback screen. So you can see how visual it is. You can see how that contraction is. It's very much right there, then you can see what they're doing. This is a patient that's reclining. It's probably an initial visit. It's a female. So the electrodes are around... And I'll show you the placement, and that she's visualizing her contraction relaxation.

So how does it work? Well, there are active electrodes, which are electrodes that pick up the electrical activity. And there's a ground electrode that really is your grounder that tries to cut out some of the noise in the room and maybe around the area. It amplifies a difference to make sure that you're picking up correctly. These are the locations of where I put the electrodes. So they should go around the introitus that they can either be 10:00 and 4:00 or 3:00 and 9:00 or they can of course go around the anus. You can also use internal sensors or probes. And on this you can see that what the EMG is picking up is, it's a long electrode which is better than being round, and that picks up the electrical activity or the contraction of the muscle. These are called surface EMGs, which means surface. So surface against the muscle or against the skin that's picking up the electrodes. One's vaginal, one's rectal.

And this is what the patient sees. So this is one example of a baseline muscle activity that's at rest, so that you should not see anything happening. The muscle at rest should be kind of flat. Anything less than two microvolts, and that's the measurement that you pick up with EMG microvolts, it should be really very quiet and rest baseline. This is a peak. So these are quick pelvic floor muscle contractions. It's the highest EMG aptitude that the patient can achieve. Patients ask me all the time, "Well, how high should it go?" Well, we don't know what the norm is, but the point is I'm not so interested in the height of the contraction as much as I'm interested in the difference between height and the relaxation. Is there a differential? So, that's important to me. And as you can see with this, as far as this patient can hold it about two to three seconds, they're trying to do a long contraction, then it drops off. So these are trying to return to baseline and unable to really sustain the contraction.

And then this is a great example of one of my patients. Initially, you see those quick contractions and you see how he tried to do the ten second holds. You can see the muscle go up and not stay up for the 10 seconds, but you try to recontract, that was a baseline. And four weeks later, look how much increased strength he has. And on this picture you can see the improvement in endurance and he's able to hold it for up to that 10 seconds. And that's kind of what you'll see in the progression. And this is very visual patients. Sometimes what I do is I print these out because they're in color and I'll give them to the patient, take home with him. A lot of times they'll say, "I want to show my husband. I want to show my wife what I'm doing, how I'm improving." So they're really a motivating factor.

So patients will ask, "How long is the session?" Usually the session's 20 to 30 minutes. But my initial biofeedback session, the first one for the patient may be as long as 45 minutes. There's a lot of counseling and education on that initial visit, especially if the patient cannot contract the muscle. I spent a lot of time with just running the EMG saying, "Okay now, concentrating on, I put my hand on their stomach I don't want the stomach to contract. It should not move. I don't want you lifting." So I watch that and making sure they're isolating the correct muscle. So it can take up to 45 minutes initially.

When do you see results? It can be three to six months. And sometimes patients get very frustrated over that, but it takes time. They're working the pelvic muscle, they're building a weak muscle, and it takes time as in any muscle that's weak or that you're not working properly. So expect maybe you'll see it in six weeks, but it may take longer. So I set up expectations and I tell patients it may take some time.

So that's what biofeedback is, and I try to set my patient up for what to expect. So, determining expectations are really important. So I'll say to patients, "You have a lot of incontinence. You're going to the bathroom frequently. You're not going to come back in two weeks and tell me everything's better. What's probably going to happen is you're going to come back and say, 'Oh, you know what? I think I have more control. I'm not wearing as many pads.'" Or what happens a lot with my men, the wives will say, "Oh, I know he is better because I'm not buying as many." I even have them say ,men and women, "I don't think I'm leaking as much because the trash bag isn't as heavy as it used to be." So they don't go around measuring their incontinence. Some of them may measure pads to see if they're more and more drier and less and less weight, but that's not usually the case. So, I tell them it may take time. And I say to them, "What's going to happen when you come back? As you may say, 'you know what? I'm voiding less. I may not be wearing as many pads or I've gone to a smaller pad because the leakage is not as severe. I seem to be urinating more, which means that bladder's holding more urine.'" Okay, because the bladder training is working. These are the type of changes that you see.

And you have to be patient and the patient has to be patient, but you have to be a motivator, and I jump on anything. When they tell me that they can suppress the urge, it works once or twice a week. I'm like, that is wonderful. That's what I expect. When they tell me they can now feel the muscle or they're using the muscle to prevent incontinence. Wow, that's really good success. In my practice years ago I would give out stars when I saw improvement. Remember we talked about behavioral training? Any kind of positive feedback you can give the patients important. Print out the graph and say, "Look, this is what you were last time that you were here. Look at where you are here." They can visualize that improvement. So you know why I like my practice is patients get better and they tell me, and they're so happy, it's really changing their lives.

So I hope this has been helpful. Please feel free to listen to the other presentations, this is as much of my knowledge I can impart to you. Thanks.