The Web-enabled Glazer Surface Electromyographic Protocol

Abstract
TeleVital Inc. has developed a browser-based software for the Glazer Pelvic Floor Muscle Surface Electromography (sEMG) protocol for remote assessment and treatment over the Internet. The initial application of this system is being conducted between the Washington D.C. offices of the second author (SCM) and remotely controlled in the New York City offices of the first author (HIG) to determine the broad scale applicability of this system in office practice.

Background
Glazer has demonstrated that several characteristics of pelvic floor muscle surface electromyography (sEMG) are statistically significant in differentially diagnosing both dysesthetic vulvodynia (DV) and Vulvar Vestibulitis Syndrome (VVS) from vulvar pain of organic origin.3,4 It has further been demonstrated that normalization of these abnormal pelvic floor muscle sEMG patterns, by use of sEMG-assisted rehabilitation, produces long term treatment benefits.1 Digital palpation of pelvic floor musculature has been demonstrated to have little clinical predictive validity while pelvic floor muscle sEMG is highly clinically predictive.2 Instructions in the conduct of unassisted pelvic floor muscle exercises have not been demonstrated as effective. There is, therefore, a need to integrate pelvic floor muscle sEMG into diagnostic workups and treatment regimens. The browser-based pelvic floor muscle sEMG protocol offers a reliable and convenient diagnostic and treatment tool that practitioners can easily access when specialized assessment is needed.
 

Case
A women with physical findings on gynecological exam, consistent with VVS was shown to have elevated resting tension and contractile weakness of pelvic floor musculature. The patient was monitored and her pelvic floor muscles assessed remotely over the Internet using the browser-based Glazer protocol software, with the option of communicating via real-time videoconferencing, instant messaging, or plain old telephone service (POTS). Video conferencing fully taps the capabilities of telemedicine by also making the nonverbal components of communication available and allowing both remote communication and observation to assure the correct use of pelvic floor muscles.

The equipment used for this protocol included a minimally invasive sEMG single-user vaginal sensor that was easily inserted by the patient in private after receiving instructions from a nurse, and a portable sEMG biofeedback instrument (Myotrac 3, manufactured by Thought Technology LTD, Montreal Canada), which connects to the serial port of the patient’s computer. Computerized sEMG data acquisition was transmitted, stored, and retrieved with TeleVital’s browser-based software, VitalWeb.TM

The patient completed an on-line intake form, including patient demographic data and information concerning the current condition, onset,k prior treatment, sexual activity and related symptoms, such as urinary frequency and urgency, low back pain and gastrointestinal symptoms. Once the intake form was completed, the remote clinician was notified and able to review the information prior to conducting a remote assessment.

After the patient had privately inserted the vaginal sensor, a session was created from the patient location through the TeleVital website using a secure login ID & password. The browser-driven software signaled when the patient was on-line and ready to begin. By clicking the "live" button, the remote clinician immediately viewed the patient’s real-time sEMG signals. The remote clinician and the patient were able to communicate and simultaneously view the real-time sEMG signals on the computer screen from separate locations. Auditory and visual cues guided the patient through the entire procedure, while The remote clinician controlled the advancement through each segment of the protocol, and adjusted the gain for optimal display.

Table 1: Pelvic Floor Muscle Surface Electromyographic Data at Initial and Terminal Evaluations.

Initial Evaluation Follow-up Evaluation

Pre-baseline mV mV

Average 6.0 2.5

Standard Deviation 1.20 0.20

True Standard Deviation 0.20 0.08

Rapid Contractions (Flicks)

Average Max 18.7 32.1

Average Relax 6.8 2.8

Tonic Relax

Average 7.5 1.8

Standard Deviation 1.50 0.20

True Standard Deviation 0.20 0.11

Tonic Contract

Average 16.8 27.1

Standard Deviation 3.02 2.44

True Standard Deviation 0.18 0.09

Average 80% Fire Time 0.67 0.20

Average 20% Recovery Time 2.36 0.54

Endurance

Average 12.3 23.8

Standard Deviation 2.34 2.37

True Standard Deviation 0.19 0.10

Post-baseline

Average 7.3 2.6

Standard Deviation 1.60 0.26

True Standard Deviation 0.22 0.10

Subjective Pain Rating (0-10) 8 0

The patient was initially asked via instant messenger to tighten her pelvic muscles to verify accurate sensor placement, signaling and to make sure that she was able to voluntarily contract the correct isolated muscle group. Once this was determined, the remote clinician advanced to the beginning of the protocol, starting with the one minute pre-baseline. The automated data collection for evaluation of the pelvic floor muscles was gathered for the following segments:

One minute resting EMG baseline period.

Five quick muscle contractions, one every 10 seconds for 5 repetitions

Five repetitions of 10-second periods alternating between rest and contract, starting with a 10-second rest followed by 10-second contracts.

Ten seconds of rest.

One 60-second contraction (endurance)

One minute post-baseline

Consistent with sexual, sphincteric and support functions of the pelvic floor musculature, and in order to look at recruitment and endurance, there are three phases to the assessment that consisted of contracting the muscles for different durations (1, 10 and 60 seconds). The contraction and intervening relaxation, maximal amplitude, minimal amplitude, mean amplitude and signal standard deviation were recorded.

After conducting a real-time, remote assessment, an auto-generated graphical and statistical summary report was displayed, which includes data fields for adding patient data, clinical notes and treatment recommendations. This report can be printed both at the protocol administrator’s and patient’s location.

The patient was given remote follow-up evaluation to ensure continued compliance with the home exercise regimen, and to assess improvement.

Data shown in Table 1 demonstrated improvement from initial assessment to follow-up session. The results indicate after an average of 24 weeks of practice, pelvic floor muscle contractions increased 61.3%. resting tension levels decreased 58.3%, and the instability of the muscle at rest decreased by 60%. Subjective reports of pain decreased 100%

Conclusion
In conclusion, a woman suffering from VVS was remotely assessed and demonstrated elevated resting tension and contractile weakness of pelvic floor musculature. Remote training of pelvic floor musculature with twice-daily exercises resulted in stronger, more relaxed and more stable pelvic muscles accompanied by a decrease in subjective pain reports.

Pelvic floor muscle instability is a critical factor in pain associated with VVS.1 A remote sEMG assessment was able to demonstrate the state of the pelvic floor. An sEMG-assisted exercise program significantly stabilized the patient’s pelvic floor muscles, and reduced the symptoms of vulvar vestibulitis as indicated by remote follow-up evaluations.

Telecommunication of electrophysiological data is already well established in some applications such as electrocardiography. Recent advances in technology provide an easy and effective way to incorporate pelvic floor muscle sEMG into a routine diagnostic evaluation or treatment plan that can be done remotely, and in real-time, over the Internet using the browser-based Glazer protocol software developed by TeleVital Inc. The browser-based pelvic floor muscle sEMG protocol offers a reliable and convenient diagnostic and treatment tool that will help practitioners overcome the barriers of distance and time, and improve continuity of care.

References:

Visit Dr. Glazer.s website at: http://www.vulvodynia.com

References

Glazer HI, Rodke G, Swencionis C, Hertz R, Young A: Treatment of Vulvar Vestibulitis Syndrome wit h Electromyographic Biofeedback of Pelvic Floor Musculature. J Reprod Med 1995;40: 283-290

Glazer HI, Romanzi, L, Polaneczky, M: Pelvic Floor Muscle Surface Electromyography; Reliability and Clinical Predictive Validity. J Reprod Med 1999;44: 779-782.

Glazer HI, Jantos M, Hartmann EH, Swencionis, C: Electromyographic Comparisons of Pelvic Floor in Women with Dysesthetic Vulvodynia and Asymptomatic Women. J Reprod Med 1998;43: 959-962.

White G, Jantos M, Glazer HI: Establishing the Diagnosis of Vulvar Vestibulitis. J Reprod med 1997; 42: 157-160.