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KEGEL
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EXERCISES
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The Bastardization Of
Dr. Kegel's Exercises
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
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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
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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
PerineometerЄ) 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.
Footnotes
1 This work was supported in part by
Public Health Service National Institute on Aging (SBIR) Grant
No. 1 R43 AG06755-01 to John D. Perry.
2 Kegel A. Stress Incontinence and Genital
Relaxation: A non-surgical Method of Increasing the Tone of
Sphincters and Supporting Structures. CIBA Symposium, 1952, p.
35.
3 Noble E. Essential Exercises for the
Child-bearing Year. Boston: Houghton Miflin, 1982 Second
Edition, p. 40.
4 Burgio K, Robinson, Engel B. The Role of
Biofeedback in Kegel Exercise Training for Stress Urinary
Incontinence. Am J. Obstet Gynecol, 1986,154:58-64.
5 Taylor K, Henderson J. Effects of
biofeedback on simple urinary stress incontinence in older
women. J of Geron. Nursing, 1986.
6 Kegel, 1956, p. 545.
7 Kegel, 1956, p. 546.
8 Kegel, 1956, p. 546.
9 Kegel A, Progressive Resistance Exercise
in the Functional Restoration of the Perineal Muscles. Am J
Obstet & Gynec August, 1948, 56:2, p. 244-245.
10 Kegel A. Early Genital Relaxation: New
technic of diagnosis and nonsurgical treatment. Obstet &
Gynec, November, 1956, 8:5, p. 545-550.
11 ibid., p. 547.
12 Kegel, A. 1956, p. 546.
13 Taylor K, Henderson, J., 1986, p. 29
14 Kegel, A 1948, p. 246-7.
15 ibid., p. 245.
16 e.g., LaRiccia & Chapman, 1987;
Smith, Smith, Rose & Kaschak, 1987
17 Wells, T. in a speech at the University
of Pennsylvania School of Nursing, October 20,1987.
18 Kegel, A. Progress in Gynecology, 1950,
p. 786.
19 ibid., p. 789.
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