The Bastardization Of
Dr. Kegel's Exercises(1)
By John D. Perry, PhD & Leslie Talcott
Hullett, MS, RN
Paoli (Pa) Memorial Hospital Continence Program
This Paper Was Presented to Northeastern Gerontological
Society,
New Brunswick, New Jersey, May 20, 1988
bas-tard n. 2. Any irregular, inferior, or counterfeit
thing. adj. 3. Resembling but not typical of the genuine thing.
bas-tard-ize v. 2. To make degenerate; debase.
- Funk & Wagnalls Standard College Dictionary
The medical establishment is as polarized about the value of
Kegel's Exercises as this country ever was over
"Vietnam" or "McCarthyism". On the one hand
"patient advocates", such as nurses and physical
therapists, insist that (l) anyone can learn to do them, (2)
everyone should learn to do them, and (3) they each know the one
"correct" way to teach them. On the other hand, most
urologists and gynecologists only politely smile at the mention
of Kegel's legacy, knowing full well that, sooner or later,
almost every incontinent person will eventually submit to a
surgical procedure or urological medication.
Explication of this paradoxical conflict is of considerable
interest to gerontologists, since Arnold Kegel, M.D., originally
proposed his exercises as an alternative to needless and
ineffective surgery2, which he perceived in his own practice and
those of his colleagues. He correctly anticipated several
contemporary medical trends, including (l) cost containment, (2)
the self-help movement, (3) women's rights, (4) the value of
isometric exercise and (5) biofeedback technology. Like
cartoonist Jules Pfiffer's youthful anti-Vietnam activist, his
primary mistake was "pre-mature morality".
Stopping and Starting the Flow. In popular
literature, Kegel's exercises are most frequently described as
those which have to do with the "stopping and starting the
flow of urine". As a simple means of pubococcygeus muscle
identification, this test is educational-but only for those who
already have strong muscles. It was never intended to be the
"instructional tool" that it has become in women's
magazines. Indeed, Elizabeth Noble even warns against this
practice, which often leads only to "anxiety, stress and
loss of control"3. Failing to interrupt the stream, many
women conclude that their own muscles are already beyond
self-help, and readily submit to the surgeon's confident
invitation. And the surgeon becomes more firmly convinced of the
futility of Kegel's exercise when one after another patient
claims that they "tried them" but "they didn't
work." Since the patient is now incontinent, that is
obviously true.
It is the thesis of this paper that the bastardization of Dr.
Kegel's exercises-the unintentional but thoroughly understandable
emancipation of the exercises from their historical parentage-has
led to a state of confusion among both professionals and
laypersons alike. This confusion is epitomized in the title of a
recent paper by Burgio, Robinson & Engel: "The Role of
Biofeedback in Kegel Exercise Training for Stress Urinary
Incontinence"4 But the title is quite misleading. Rather
than investigate the role of biofeedback in Dr. Kegel's exercise,
the authors present a controlled experiment in which exercises
are prescribed with and without biofeedback. A false dichotomy is
drawn between "Kegel Exercises", by which the
researchers mean merely verbal instruction without biofeedback,
and "Biofeedback", by which was meant verbal
instruction in pelvic muscle exercise with concomitant direct
visual feedback of that muscle activity. Naturally the
instruction-with-biofeedback condition proved considerably more
effective than instruction-without-biofeedback. This should
surprise no one, since this model of research has been replicated
many times in the literature about biofeedback in general. For
example, countless studies have shown that various forms of
relaxation training (for stress management, for example) are
significantly better when physiological feedback of muscle states
and peripheral temperature augments mere verbal instruction.
What is distressing about this NIA research is not that it
proves the superiority of biofeedback, but that it validates the
bastardization of Dr. Kegel's exercises by hypothesizing
therapeutic efficacy to an emaciated version of them. This is an
illegitimate distortion of historical scientific research. Most
researchers know that Kegel's claims were based on exhaustive
clinical records of patients seen at the Perineometer Research
Institute at UCLA. (The actual number of patients seen is often
under-reported by scholars who may have read only one or two of
Kegel's earlier papers. For example, Taylor and Henderson remark
that Kegel did his research "on small groups of women"5
But in his 1956 film and later papers, Kegel refers clearly to
"several thousand women"-hardly a small group!)
Moreover, we cannot be impressed by sophomoric complaints that
Kegel's sample was "not scientific" because he did not
validate his exercises with controlled experiments. Chi Squared
is only one form of statistic. In cases where we already know the
success rates for of untreated populations and of alternative
therapies (such as surgery), it is only necessary to show that
the new treatment improves significantly upon the previous
options. If the data are unclear, a "t-test" can be
employed. But a statistical test is quite unnecessary with the
unmistakable data generated in Kegel's clinic.
Kegel's Three Steps.
Kegel clearly stated
that there were three steps to his method. "The first step
is external observation, with the patient in the lithotomy
position."6 Kegel first observed the patient's ability to
visibly draw up the perineal structures. "The second step is
vaginal examination, performed gently with one finger."7 The
digital exam served a double purpose: first, it enabled the
physician to assess the development of the puboccocygeus muscle
at various depths, and second, it enabled the physician to verify
that the patient was able to identify the correct muscle and
contract it. Thus identification of the muscle, and not its
exercise, was the purpose of Kegel's digital exam. The third
stage follows quickly: "after [only] 5 to 10 correct
contractions the Perineometer is inserted, and both physician and
patient watch the manometer to note the results of her
efforts"8 (emphasis added). In several articles, the
insertion of the Perineometer biofeedback device marks the
beginning of the third and primary step in Dr. Kegel's exercise
program.
It is important to observe that Kegel defined his exercises
"operationally", rather than "formally". That
is, rather than specify "how to do the exercises", he
specified what would be measured if they were done correctly with
his device in place. He invented and used the world's first
biofeedback instrument, the perineometer, to objectively assess
pelvic muscle strength, both in the office, and in daily at-home
use by the patient.
Importance of biofeedback for Kegel. Kegel's
own reliance on his perineometer is clearly documented in all of
his writings. For example:
"Patients vary greatly in their ability to contract the
vaginal muscles. Many, especially those with marked relaxation of
the pelvic floor, are unable to register even a few millimeters
of pressure on their initial attempts. Gradually, after practice,
and as the muscles become stronger through exercise, the pressure
which can be exerted increases and frequently reaches 60 to 80 or
more millimeters of mercury.9
"The perineometer is employed to measure strength of
contractions. Normally, a slight increase of 1-5 mm Hg will be
registered at first visits, provided the exercises have been
carried out correctly.... If at the second or third visit the
patient does not report some slight relief of symptoms, the
reason is immediately investigated.... The physician need not
depend on the patient's word alone, for lack of diligence betrays
itself by rapid fatigue, as revealed by lower Perineometer
readings after only 3 or 4 contractions.10
Kegel often stressed the "resistive device" function
of his vaginal probe in anticipation of isometric exercises. But
he was also aware of what later came to be called
"behavioral principles" when he wrote: "A woman
who is able to observe the slow but steady day-by-day progress on
the manometer will be encouraged to keep up the good
work."11 B. F. Skinner couldn't have said it better.
Kegel did mention the interruption of the urinary stream, but
not at all in the context which his less-than-faithful followers
have. Urinary interruption was not proposed as a means of
locating the muscle, but as one of many daily opportunities to
practice exercising it in the advanced stages of therapy.
The Digital Exam and Subjective Measurement.
Recently two nursing professors (Dougherty and Wells) have
independently tried to promote the digital examination itself as
a subjective measure of pubococcygeus strength. But Kegel
himself-while making it the second step in his program-was
acutely aware of its limitations. "The strength of the
puboccocygeus muscle can be roughly estimated by digital
palpation," he said, "or more accurately measured with
the Perineometer"12. Admittedly his numerical scale was, by
today's standards, itself a bit rough. The quotation continues:
"Contractions of 5 mm Hg or less denote pronounced weakness
of the perivaginal muscles, readings of 20-50 mm Hg indicate good
development of the musculature, while intermediate values suggest
borderline conditions."
Contemporary forms of perineometry, based on electronic
sensors and computerized instruments, permit considerably finer
precision in recording and averaging muscle data than was
possible in Kegel's day. This has led Taylor and Henderson13, for
example, to delineate "10.85 microvolts" (EMG reading
on the Personal Perineometerª) as "the mean reading at
which our subjects were dry", and 12 microvolts as the
absolute level for urinary control. Modern perineometry is also
considerably more sensitive than the manometric system employed
by Kegel. EMG instruments are capable of detecting muscle action
potentials far below the level necessary for an actual
contraction of muscle fibers to occur (i.e., below
"trace"). In other words, today's EMG perineometers are
capable of confirming the patient's identification of the PC
muscle at far lower levels than even Dr. Kegel's experienced
fingers could palpate. While the digital examination may retain
some value in the physician's initial assessment of the muscle's
development, it is probably no longer the best means of helping
the patient identify the muscle.
Amount of Exercise Prescribed. Kegel
routinely prescribed a therapeutic regimen of a full hour a day
of practice with his Perineometer device in the vagina. No where
does he mention the duration of a single contraction, but he
states that "twenty minutes, three times a day, or for a
total of 300 contractions daily". Sixty minutes times 60
seconds equals 3600 seconds, divided by 300 repetitions allows
for 12 second cycles. In his drawings of "pressure over
time" he sketches symmetrical sine waves, and he remarks
that in the final, healthy stage contractions become
"prolonged"14, so we can conclude by simple arithmetic that he envisioned six-second contractions.
The role of the Kegel Perineometer as a "home
trainer" with quantifiable biofeedback signals was quite
clear to Kegel. "While the patient is exercising regularly,
she is encouraged to attempt to increase the pressure 1 to 2 mm
of mercury daily, and to keep a record of the maximum contraction
of which she is capable at each exercise period."15 More
recent disciples have made the use of the Perineometer home
trainer either optiona116, or dispensed with it all together.
Recently Wells explained that the federally-funded Ann Arbor
program decided against the use of home trainers because they
feared "sexual arousal" among their patients.17 Kegel
disagreed:
"The physician's explanation of the therapy need not and
should not be made in an apologetic attitude. The method is
presented to the patient in a factual manner, stressing the
necessity for restoration of dormant muscle function. The
objection that sexual stimulation may be brought about through
exercises with the perineometer is sometimes intimated by
physicians, but has no basis in fact in normal women. As long as
no unsound associations are suggested the patient will appreciate
the simplicity and practicability of the therapy."18
[In our own experience with over 100 incontinent patients,
less than two percent have even commented on sexual connotations
of the (EMG) perineometer sensor, and none have objected to the
daily use of the "home trainer" biofeedback device.]
Success of Kegel's Method. By 1950 Kegel was
able to boast a 93% cure rate for 300 unselected patients with
stress incontinence in Los Angles, and claimed that other
physicians using his device were 91% successful. Beginning in
1948, "on the strength of these favorable results urinary
stress incontinence in women is no longer routinely treated by
surgical intervention at...LA County General Hospital."19
But the promise of Kegel's exercises has yet to be fulfilled.
Some origins of Kegel's demise are self-evident. Among
surgeons at least, the goal of eliminating surgery is no more
popular in 1988 than it was in 1948. Judged by, for example, the
Proceedings of the International Continence Society over the past
few years, the profession is committed to finding new and better
surgical techniques; not fewer surgical opportunities. It bears
noting also, that while Kegel himself was a surgeon, the
contemporary advocates of his exercises are almost exclusively
drawn from the ancillary medical professions.
Unfortunately, history found it easier to transmit Kegel's
words than his device. The latter was marketed for many years by
Kegel and his wife, who assembled the components-literally-on
their kitchen table. Mrs. Kegel diligently continued the practice
for three more years following his death in 1976, but she finally
retired in 1979. The gradual decline of the device may be
reflected in its inappropriately stable price: from 1947 to 1979,
it always sold for the same $39.95 at which it was first
introduced. Lacking ordinary commercial incentives, the medical
equipment industry lost interest in the perineometer. Lacking his
perineometer, medical personnel were forced to improvise on his
methods. The results of trying to teach Kegel's exercise without
his measuring device have been less than impressive. Fortunately
there is now a movement to restore biofeedback to its rightful
place as an integral part of Dr. Kegel's exercises, and thus
restore full credit to one of America's greatest pioneering
physicians.
The PelvicToner addresses the fundamental principles dictated by Arnold Kegel
- identify and isolate the correct muscle, then exercise it using a progressive
resistance with the appropriate feedback mechanism. To read how the PelvicToner
achieves this click here.
footnotes
1This work was supported in part by Public Health Service
National Institute on Aging (SBIR) Grant No. 1 R43 AG06755-01 to
John D. Perry.
2Kegel A. Stress Incontinence and Genital Relaxation: A
non-surgical Method of Increasing the Tone of Sphincters and
Supporting Structures. CIBA Symposium, 1952, p. 35.
3Noble E. Essential Exercises for the Child-bearing Year.
Boston: Houghton Miflin, 1982 Second Edition, p. 40.
4Burgio K, Robinson, Engel B. The Role of Biofeedback in Kegel
Exercise Training for Stress Urinary Incontinence. Am J. Obstet
Gynecol, 1986,154:58-64.
5Taylor K, Henderson J. Effects of biofeedback on simple
urinary stress incontinence in older women. J of Geron. Nursing,
1986.
6Kegel, 1956, p. 545.
7Kegel, 1956, p. 546.
8Kegel, 1956, p. 546.
9Kegel A, Progressive Resistance Exercise in the Functional
Restoration of the Perineal Muscles. Am J Obstet & Gynec
August, 1948, 56:2, p. 244-245.
10Kegel A. Early Genital Relaxation: New technic of diagnosis
and nonsurgical treatment. Obstet & Gynec, November, 1956,
8:5, p. 545-550.
11ibid., p. 547.
12Kegel, A. 1956, p. 546.
13Taylor K, Henderson, J., 1986, p. 29
14Kegel, A 1948, p. 246-7.
15ibid., p. 245.
16 e.g., LaRiccia & Chapman, 1987; Smith, Smith, Rose
& Kaschak, 1987
17Wells, T. in a speech at the University of Pennsylvania
School of Nursing, October 20,1987.
18Kegel, A. Progress in Gynecology, 1950, p. 786.
19ibid., p. 789.
Reprinted 2/90, HTML 10/95
Downloaded from "Incontinence on the Internet" - at
http://www.incontinet.com/articles/art_urin/bastard.htm.
The PelvicToner addresses the fundamental principles dictated by Arnold Kegel
- identify and isolate the correct muscle, then exercise it using a progressive
resistance with the appropriate feedback mechanism. To read how the PelvicToner
achieves this click here.
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