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At Cleveland Clinic Florida, all patients are requested to keep a 3- to 7-day diary of bladder and bowel habits, laxative, enema, or suppository use, fluid intake, number of home exercises completed, fiber intake, and any associated symptoms of constipation or incontinence.

The initial session begins with a history and description of the anatomy and physiology of the bowel, bladder, and pelvic muscle function using anatomic diagrams and visual aids. This is followed by a description of the biofeedback process, instrumentation, and PMR exercises. Results are not immediate; as with any exercise program, muscle improvement requires time and effort. The initial goals of isolated pelvic muscle contractions are established and an example of an 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. Surface electrodes are then placed on the right abdominal quadrant along the long axis of the oblique muscles, used to monitor abdominal accessory muscle use. The cables are attached to the SRS Orion PC/12 (SRS Medical Systems, Inc., Redmond, WA) multimodality instrumentation that provides the ability to simultaneously monitor up to four muscle sites

(Figure 12-1.2). Electromyography specifications include a bandwidth of 20 to 500 Hz and 50/60 Hz notch filter. Surface EMG 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 more than 2 ||V may be associated with dyssynergia, voiding dysfunction, and pelvic pain. Jacob-son's progressive muscle relaxation strategy implicates that, after a muscle tenses, it automatically relaxes more deeply when released. 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 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, along with vaginal prolapse. Multifactorial concomitant PFM dysfunction accounts for the rationale to initiate all patients with isolated symptoms on comprehensive pelvic muscle rehabilitative therapy. Home practice recommendations depend on the observed decay in the duration of the contraction accompanied by the abdominal muscle recruitment. 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 3 to 4 contractions seen in patients with weak PFMs. An example of home practice may begin with the patient performing an isolated PFM contraction, holding for a 5-second duration, relaxing for 10 seconds, and repeating 3 to 10 times, which constitutes one set. One set is performed 3 to 5 times daily, at designated intervals, allowing for extended rest periods between sets. The lower the number of repetitions, the more frequent interval sets should be performed daily. Excessive repetitions may overly fatigue the muscles and exacerbate symptoms.

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 and Valsalva maneuvers, depending on the patient's progress. These objective measurements gauge improvements in muscle activity that should be seen with each visit and occur before 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, habit training, physiologic quieting, anorectal coordination maneuvers, altering fiber and fluid intake, increasing activity and/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 because of underlying conditions. Therefore, patients should be directly involved in setting their treatment goals. Some patients may be satisfied simply with the ability to leave home without fear of a significant relative fecal accident. Improved quality of life and patient satisfaction should be considered a treatment success.

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