125 Effect of Relaxation Training Augmented by EMG in Treating Vaginal Spasm

Salwa M. El-Badry, PT.D.* and Heba G. Kotb, M.D.** *Department of Physical Therapy for Gaynecology & Obstetrics, Faculty of Physical Therapy, Cairo University. **Department Of Forensic Medicine, Faculty of Medicine, Cairo University.

ABSTRACT

This study was conducted to determine the effect of relaxation training augmented by EMG biofeedback in treating cases suffering from vaginal spasm. Twenty volunteer newly married women, diagnosed as having primary , participated in this study. They were collected from Gynecologic outpatient clinic at Kasr EL-Aini university Hospital. Their age ranged from 25-35 years and their duration of marriage ranged from 2-7 months. Each subject was treated by relaxation training and EMG biofeedback, twice/week for three weeks, in addition to daily home routine. Assessment was done by present pain intensity (PPi) scale and TG Myo-feedback 420v, before starting the study and at the end of the 6th treatment session. Results showed statistical highly significant (P<0.001) decrease in both PPi scores and pubococcygeus muscle spasm after the end of the 6th treatment session. Accordingly, it could be concluded that relaxation training augmented by EMG biofeedback is an effective physical therapy modality in treating patients suffering from primary vaginismus. Keywords: Vaginal Spasm, Relaxation Training, EMG Biofeedback, Primary Vaginismus.

INTRODUCTION the term to describe vaginal penetration difficulties. ainful genital sexual activity in Gynecological examination can confirm women has traditionally been the diagnosis of vaginismus and determine diagnosed as either vaginismus and / whether there is an involuntary muscle or dyspareunia, it is neglected, and contraction when fingers are inserted into Ppoorly understood. It entails great personal cost and this usually produces the pain that to patients and significant financial outlay for the woman feels with intercourse11. society5,9,34. The vast majority of women diagnosed However, vaginismus is recommended with vaginismus experience pain during a as the presence of "vaginal spasm", so that gynecological examination and during there is reflexive involuntary contraction of the attempted intercourse18,26. Moreover, pelvic muscles as well as, thigh adductors, avoidance of penetration appears to be the abdominal muscles, muscles of the back and only factor that differentiates between limbs, associated with varying degrees of fear vaginismus and dyspareunia10,14,26. of pain, typically but not invariably precludes Vaginismus could be physical or full entry of a penis, tampon, speculum or psychological in nature. Physical causes vary finger2. from an imperforated hymen, a dry atrophied So, vaginal spasm has rarely questioned vagina to even endometriosis. While, as the defining characteristic for the diagnosis psychological causes may vary from the of vaginismus since Sims (1861)30 first coined dislike of partner, rape, incest, childhood

Bull. Fac. Ph. Th. Cairo Univ.,: Vol. 12, No. (1) Jan. 2007 126 molestation, fear of penetration and pain near until the need to expand and relax. This the vaginal area26. relaxation allows intercourse, , Concepts such as penetration, medical examination and insertion of tampons. intercourse and even sex can cause fear or However, when vaginismus does occur, the trepidation in the mind of a young sphincter goes into spasm resulting in the inexperienced woman who may hear stories tightening of the vagina and with some about painful first intercourse, which then women, vaginismus prevents all attempts of reinforce the fear of penetration. This fear can successful intercourse2,25. compound and create a pattern of sexual Surrounding the entrance of the vagina, anxiety, causing the vagina to remain dry and there are a very powerful pubococcygeus (PC) unrelaxed before intercourse7. muscles. The PC muscle group has a key role Fear of penetration and pain may in the function of reproductive system, urinary develop from inadequate sex knowledge, tract, and bowels. These muscles enable one to myths and misconceptions, as well as from the urinate, have intercourse, , have bowel stories of painful sexual intercourse movements, and deliver babies. Hence, they experiences narrated by others. Mostly, stories are also, sometimes referred to as love of pain and bleeding, during the first attempts muscles, vaginal muscles, or of penetration, horrify the one who has not yet muscles. These muscles encircle the urinary undergone penetration15. opening, vagina, and anus in a "figure eight" Whatever is the cause, the anticipating pattern. One loop of muscles surrounds the pain during the next attempt of penetration, vaginal area and the other loops surround the send signals from brain to the muscles around anal area. Contractions of the pelvic floor vagina, to tight the vaginal opening. As a muscles may occur as a result of local pain result, the vagina is so tightly closed that caused by vaginal dryness, recent childbirth, or attempted penetration becomes more difficult abdominal as well as, back pain20. and more painful. Finally the whole process It is important to note that the PC goes beyond the woman's conscious control7. muscles spasm is not triggered deliberately by Involuntary vaginal spasm caused by the woman but rather it happens contraction of the pelvic floor muscles "unconsciously"; possibly even without her following attempts of vaginal penetration may awareness. This involuntary spasm can happen be primary, requiring psychosexual counseling for a variety of reasons as a response to a or, secondary where the underlying pathology combination of physical or emotional factors needs to be firstly treated and then, followed and is considered the body's erroneous way of by re-education of the pelvic floor muscles33. protecting itself. Not knowing why this Hence, involuntary spasm of the happens, what causes it, or how to treat it, can pubococcygeus muscle usually occurs in be very frustrating and causes physical and anticipation of pain and if penetration is forced emotional distress for both the woman and her through the tight muscle, pain will be partner. Many women feel intense shame from experienced8,32. being unable to have intercourse and they keep Vaginal tightness, difficulty or inability their pain inside private, refusing to share their to allow penetration for intercourse is the secret with anyone5. primary symptom of vaginismus. Normally, The main goal of physical therapy is to the vaginal sphincter keeps the vagina closed rehabilitate the pelvic floor by (1) increasing

Bull. Fac. Ph. Th. Cairo Univ.,: Vol. 12, No. (1) Jan. 2007 127 awareness of the pelvic floor musculature; (2) inner thigh and pelvic area. Kegel's exercises improving muscle discrimination and muscle may also, assist by increasing control and relaxation; (3) normalizing muscle tone; (4) voluntary relaxation. So, kegel exercise can increasing elasticity of the tissues at the help to gain voluntary control over pelvic vaginal opening, and (5) decreasing fear of muscles. The goal of kegel exercises is not to vaginal penetration. These goals are achieved tense the muscles, but to learn to relax them24. through education about the role of the pelvic Insertion of graded trainers (vaginal floor musculature in the maintenance of dilators) or fingers, after engaging in genital pain, electromyographic (EMG) relaxation exercises. Trainers come in a biofeedback, manual techniques (e.g. number of sizes. The smallest trainer is about stretching) and insertion techniques6,28. the size of a pencil while, the largest trainer is Biofeedback is a tool to help our mind the size of an erect penis. The individual is and body to communicate better with one taught how to painlessly insert the smallest another. Body signals that are usually below trainer by using lubricating gel and targeted the threshold of conscious awareness can be relaxation of the pelvic floor muscles12,16,24. amplified so that, the mind can "hear" them. As primary vaginismus is considered one With this awareness, the conscious mind can of the most frequent gynecological and sexual learn to "talk" to the body and gain the ability dysfunction, which cause pain and so, to control, or "self-regulate", many things that develops anxiety and fear regarding coitus and the body is doing. This is true even of many penetration. This case is usually reflected on body processes that were once thought to be the psychological state of the woman and completely automatic and impossible to cause relationship problems. So, it is important regulate through conscious control. Thus, to find a way to inhibit these excessive biofeedback can be used for greater body (and activities of the pelvic floor muscles and to self) awareness, for more optimal health and relax them to allow sexual relationship to function19,27. occur and so, allowing woman to live her life The most proper treatment for happily. vaginismus is an extensive therapy program The purpose of the present study was to that combines education and counseling with determine the effect of relaxation training behavioral exercises. Exercises include pelvic augmented by EMG biofeedback in treating floor muscle contraction and relaxation (Kegel patients suffering from vaginal spasm. exercise) to improve voluntary control24. Training the PC muscle group to respond SUBJECTS, MATERIAL AND differently to the anticipation of intercourse METHODS the key to the successful treatment of vaginismus. The process of learning to take Subjects conscious control of this muscle group will Twenty volunteer newly married systematically change the conditioned reflex women, diagnosed as having primary so that, spasms no longer occur15. vaginismus, they were collected from Progressive muscle relaxation exercise Gynecologic outpatient clinic at Kasr El-Aini will lower the individual's general muscle University Hospital, to determine the effect of tension and anxiety. In particular, the woman both relaxation training and EMG biofeedback will need to learn to relax muscles around the in treating such cases.

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All the subjects had the following mild pain = 1, moderate pain = 2, severe criteria: their age ranged from 25-35 years old pain = 3, and unbearable pain = 4. So, the with a mean value of 29.55±3.14 yrs, body patient was asked to mark the point mass index (BMI) ranged from 23.42-29.30 corresponding to her perception of pain31. kg/m2 with a mean value of 25.22±1.85 kg/m2 , - TG MYO - feedback 420v machine and their duration of marriage ranged from 2-7 (combined apparatus for myo-feedback and months with a mean value of 4.35±1.53 electro-stimulation), it has all features of a month, they had no gynecological diseases as genuine Gymna® – device: reliability, vulvar vestibulitis, vulvar pain, clitrodynia, durable quality, safety and a function vulvar dysesthesia or any pelvic inflammatory design. It was used for objective evaluation diseases, as well as no lower urinary tract before starting the study and after the end infection, neurological problems, also, they of the 6th treatment session to assess the had no past or present psychological pubococcygeus muscle spasm for each disturbances, no history of participation in patient in this study. Also, it was used as a relaxation training within the previous 6 treatment method (sensory and visual months and not under any medical treatment. feedback), twice weekly for 3 weeks. Each subject was suffering from pain Technical Features of TG MYO – Feedback and spasm in the vagina at any attempt of 420v machine: vaginal penetration. Mains voltage of 230 vac/50 / 60 Hz; tolerated Informed consent form had been signed mains voltage variations of – 10% / + 6%; from each subject before starting the study, number of channels are 2; power consumption: indicating her voluntary participation in this in operation of max. 30 w, while in stands-by: study. max. 11w; main fuses of 2 × 0.5 AT; Subjects were treated by relaxation sensitivity → EMG measuring and pressure training and EMG Biofeedback, twice weekly measuring of a scale ranging from 5 - 2600 μ for three weeks. And, they were evaluated v, and 5 – 2600 mm Hg respectively; weight of subjectively by present pain intensity (PPi) 3.5 Kg; and manufacturer of gymna®. Type of scale and objectively by TG Myo-feedback output signal of constant voltage; current form 420v before starting the study and after the end of two-phase symmetric rectangular pulse; of the treatment program. pulse frequency from 1 to 250 Hz; pulse width from 10 to 400 μ s, and with fixed polarity + Instrmentaions and - , or alternating polarity. Hardware - Recording data sheet All data and current limitation of 255m A; software current information of each patient participating in limitation of 130v and measured values + this study were recorded in a recording accuracy of output current in milli Ampere: sheet. typical +/- 10%. - Weight - height scale was used to measure - Dilators Are stainless-steel Hegard dilators, the height and weight of each subject in set of 18 cylinders, with varying sizes this study. ranging from 1 to 18.5 mm diameter (made - Present pain intensity (PPi) scale (0-4) was in Pakistan). The appropriate dilators are scored before starting the study and after inserted into the vagina in privacy to force the end of the 6th treatment session. Pain the muscles around the vagina to stretch or intensity was scored as being: no pain = 0, relax and so, allow penetration.

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- Condoms and Ky – gel Condoms were she observed as well as, listened to her own used for covering the vaginal probe to regular breathing in order to achieve mental prevent cross infections, and Ky – gel was relaxation. The TG Myo-feedback 420v used for lubrication. machine was switched on following zero - Cotton and disinfectant solution to clean program (relaxation mode), and one of the two the vulva and perineum of the patient as channels was selected, after that the wire of well as, both the vaginal electrode and the vaginal electrode connected to the socket dilators. of the selected channel (A). Accordingly, light - Pillows, cushions and sheets Pillows and signal was reflected on the bar-graph of the cushions were used to support and channel (A). This light signals, were reflected accommodate the subject body curves and the pre treatment data (μv) of the muscle parts in a comfortable relaxed position, activity (spasm) of the pubococcygeus muscle. while sheets were used to cover the Then, at the end of the evaluative procedure, patients. the TG Myo-feedback 420v machine was switched off and the vaginal electrode Procedures withdrawed from the vagina and cleaned after Evaluative procedures: (were done before removing the condom. And, 5 mins of starting the study and after the end of the 6th circulatory ex's (for both upper and lower treatment session). extremities), connected with breathing ex's Each patient participated in this study was were performed by the patient before getting instructed carefully about the evaluative as up for circulatory adjustment. This evaluative well as, treatment procedures to increase her procedure was repeated again, after the end of interest and motivation, in addition to obtain the 6th treatment session to record the post her confidence and cooperation. treatment data of pubococcygeus muscle Each patient was asked to empty her bladder activity. before starting either the evaluative or Treatment procedures treatment sessions. Then, the patient in a quite The first treatment session was started room, assumed a comfortable relaxed crook with careful explanation of the nature of the lying position, with the aid of soft pillow problem, followed by education for each behind her head and, small cushions under her patient in the study, including information pelvis as well as, knees and feet apart to assure about sexual anatomy and physiology, sexual optimal pelvic floor relaxation. And, the response cycle as well as, common myths patient was asked to estimate her experienced about sex to gain their confidence and present pain intensity on the PPi scale cooperation. according to her perception of pain. After that, the patient placed in a privacy The vaginal electrode of TG Myo-feedback quiet room (where she felt safe and 420v was cleaned, covered by condom and comfortable), in which there were no optic, lubricated by Ky-gel, after that introduced tactile or auditory stimuli, also there should be gradually and gently inside the vagina, while no restrictive clothes, and the patient assuming the patient performing panting breathing. a comfortable relaxed crook lying position, Hence, the patient was asked to relax, through soft pillows and cushions were used to support keeping her eyes as well as, mouth closed, and and accommodate the patients' body curves. keeping all her body parts well supported, then The patient was asked to close her eyes as well

Bull. Fac. Ph. Th. Cairo Univ.,: Vol. 12, No. (1) Jan. 2007 130 as, mouth gently, and perform deep breathing electrode and verbal feedback from the as a key for mental relaxation, for 5 mins. therapist, all complement one another to teach Then, the patient was asked to perform and educate the patient about pelvic floor relaxation training in form of tens-relax muscle awareness. The duration of EMG technique as the patient was asked to flex her biofeedback was 10 mins. fingers, felt the tension and its site and relax as And, after the end of the treatment well as, felt the absence of tension. This session, circulatory adjustment was done for 5 procedure was then, repeated with breathing mins, before the patient getting up. control, for all movements of both upper and This treatment procedures were repeated lower extremities, in addition to facial, twice/week, for 3 weeks (6 treatment abdominal, gluteal, pubococygeus and sessions), with instructions to avoid any stress adductor muscles for 10 mins. and practicing carefully the daily home After that, a suitable lubricated dilator routine. inserted gradually and gently into the vagina to Daily home routine: allow the transvaginal muscle to slightly 1- The patient was encouraged and instructed stretched and relaxed, for 5 mins. to practice general body relaxation (both After that, the patient was educated and mental and physical) for 20 mins. instructed carefully about kegel ex's (How to 2- And, then the patient perform kegel ex's, contract as well as, relax the pubococcygeus 10 times and increase number of muscle, and feel the difference between them), repetitions 5 times daily. for 10 mins. 3- Then, insert and withdraw the dilator Then, the vaginal electrode of TG Myo- (gradually increase the size of the dilator), feedback 420v was covered by condom and in privacy, on her own bed, twice daily (at lubricated by Ky-gel, after that introduced afternoon and at evening) for 3 weeks. gradually and gently inside the vagina, while After that, the patient was encouraged to the patient was completely relaxed (mental & enjoy her sexuality. physical). 4- Before the end of the treatment program (2 The TG Myo-feedback 420v machine sessions) each patient was informed and was switched on following zero program instructed to train herself to be completely (relaxation mode), this procedure was relaxed (mental and physical), prior to the performed the same as in the evaluative received sexual excitation. procedure. During EMG biofeedback, the patient Statistical Analysis could see and recognize the effect of her The collected data were fed into involuntary pelvic floor muscle contractions as computer for statistical analysis, using SPSS a light signal, that was reflected on the software and the statistical significance at a bargraph of channel (A), which in turn prevent confidence of 95% (level of significance 0.05). penetration. So that, the patient learned how to contract and relax on volition her pelvic floor RESULTS muscles, and this was initiated by moving the vaginal electrode in an in-and-out motion. In the present study the effect of Accordingly, visual feedback from the relaxation training augmented by EMG bargarph, sensory feedback from the vaginal biofeedback on treating and alleviating pain as

Bull. Fac. Ph. Th. Cairo Univ.,: Vol. 12, No. (1) Jan. 2007 131 well as, spasm in cases suffering from primary of cases experienced complete relief of pain vaginismus were studied. (no pain), some 25% of cases experienced As shown in Table (1), the percentage of mild pain, and few 5% of cases experienced present pain intensity scores which moderate pain. Comparing the results by using experienced by the patients before starting the chi-square the difference was found to be study were 80% of cases experienced statistically highly significant (P < 0.001) unbearable pain and the rest of cases 20% decrease in the experienced pain after the end experienced severe pain. While, after the end of the 6th treatment session. of the 6th treatment session, the majority 70%

Table (1): The percentage of PPi scores before starting the study and after the end of the treatment. Before starting the study After the end of the study

No. % No. % Unbearable Pain 16 80% -- -- Severe 4 20% -- -- Pain Moderate Pain -- -- 1 5% Mild -- -- 5 25% Pain No -- -- 14 70% Pain Chi-Square 4.09 P. Value P < 0.001

Also, Table (2) and Fig. (1), represents with a mean value of 0.35±0.58. Comparing the present pain intensity scores which between the mean values of pre and post experienced by the patient before starting the treatment program, the difference was found to treatment, in which it ranged between 3 and 4 be statistically highly significant (P < 0.001) with a mean value of 3.80±0.41, while the decrease of the experienced pain after the end experienced pain after the end of the 6th of the treatment. treatment session was ranged between 2 and 0,

Table (2): The Mean Values of PPi scores before starting the study and after the end of the treatment. Before Treatment After Treatment Mean 3.80 0.35 S.D. ± 0.41 ± 0.58 Mean Difference 3.45 t – Value 17.39 P – Value P < 0.001

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4 3 2

PPi scores 1 0 Before Treatment After Treatment

Fig. (1): The Mean Values of PPi scores before starting the study and after the end of the treatment.

And, as shown in Table (3) as well as, after the end of the 6th treatment session. Fig. (2), the pubococcygeus muscle spasm, Comparing between the mean values of pre which measured objectively by TG Myo- and post treatment, the difference was found to feedback 420v, before starting the study, was be statistically highly significant (P < 0.001) ranged from 51 to 96 μv, with a mean value of decrease in the pubococcygeus muscle spasm 80.45±13.48 μv, while it was ranged from 5 to after the end of the treatment. 25 μv with a mean value of 15.50±6.76 μv

Table (3): The Mean Values of pubococcygeus muscle spasm before starting the study and after the end to the treatment. Before Treatment After Treatment Mean 80.45 15.50 S.D. 13.48 6.76 Mean Difference 64.95 t – Value 32.55 P – Value P < 0.001

100

50 ms. spasmms. (µv) Pubococcygeus 0 Before Treatment After Treatment

Fig. (2): The Mean Values of pubococcygeus muscle spasm before starting the study and after the end of the treatment.

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DISCUSSION EMG biofeedback is an effective method for learning muscle relaxation, which is Results of the present study showed acceptable to the patients, and increased the evidence of greater improvement of the treated success rate by minimizing P.C. muscle spasm cases, in which pain as well as, spasm which in cases suffering from vaginismus. And they were experienced by the patients who stressed at the end of their study on the suffering from primary vaginismus. So, the importance of follow-up of the treated results revealed that there were statistically patients. highly significant (P<0.001) reduction of both Regarding to the pubococcygeus muscle pain and pubococcygeal spasm after the end of spasm, the results of the present study, showed the treatment program. a highly significant (P<0.001) decrease in the Concerning the present pain intensity pubococcygeus muscle activity after the end of which experienced by the patients, the results the treatment program, compared of the initial showed a statistical highly significant values before starting the treatment. This result (P<0.001) reduction of pain perception after agree and confirmed with that of Glazer12, who the end of the 6th treatment session, this result concluded that the application of EMG is agree and confirmed with that of Paul et biofeedback focus on increasing contractile al.,22 who reported a significant reduction of amplitude (strengthening) and reducing resting RR in healthy subjects after practicing amplitude (relaxation). He added that previous biofeedback relaxation technique. This applications of EMG biofeedback for treating reduction could be attributed to the effect of pelvic floor muscles related disorders viewed a relaxation in promoting parasympathetic direct consequence of pelvic floor muscle activity3 and so, alleviating and controlling the dysfunction, weakness or hypertonicity. And, vaginismic pain which experienced by the he recommend that all women should have a patients. pelvic floor assessment annually for early Also, Paul et al.,22 mentioned that detection and prevention of pelvic floor biofeedback relaxation training, modulate the dysfunction either due to weakness or traffic over vagal pathways, which is attributed hypertonicity. to the fact that breathing is considered as a key Also, Bergeron et al.,4 proved that EMG for relaxation, and so, it is associated with biofeedback has been used as a part of increased parasympathetic activity as well as, behavioral treatment program, with the reduction in sympathetic activity23. assumption that the ability to reduce muscle Accordingly, relaxation training as well tension in cases complaining from vaginismus. as, EMG biofeedback reduces anxiety, The result of this study is in agreement irritability and stresses, which could be also, with that of Sea et al.,29 who proved that attributed to the decrease in neuromuscular biofeedback is an effective aid, to learn muscle activity during relaxation that leading to control (relaxation) for patients suffering from decreased proprioceptive input to the vaginismus. hypothalamus, which decrease the activity of Bergeron and Josée Lord,5 attributed this sympathetic nervous system and so, decrease improvement to visual feedback from the the state of cerebral cortex excitability17. computer screen, verbal feedback from the The results of this study were confirmed therapist and sensory feedback from the with that of Barnes et al.,1 who concluded that vaginal probe or therapist's fingers in the

Bull. Fac. Ph. Th. Cairo Univ.,: Vol. 12, No. (1) Jan. 2007 134 vagina, and so, all complement one another to complete sexual intercourse, and one of them aware as well as, teach women about their got pregnant. pelvic floor musculature. However, they added Finally, this study confirms and adds that the combination of biofeedback and strong evidence that relaxation training manual techniques helps women to learn how augmented by EMG biofeedback, is an to contract and relax their pelvic floor muscles excellent additional physical therapy method adequately. Accordinglly, they stressed that for treating pain as well as, spasm in patients when patients trained to learn both proper suffering from primary vaginismus. muscle contraction and complete voluntary relaxation, skills that they could then, carry Conclusion over into sexual intercourse. And, they The results of this study objectively mentioned also, all physical therapy demonstrates the potential of relaxation techniques are performed first in the office by training augmented by EMG biofeedback as an the therapist and then, taught to the patient and effective non-pharmacological method for her partner as part of a home exercise treating patients suffering from vaginal spasm. program. Also, the results of this study supported REFERENCES and agreed with that of Mac kay et al.,21 who proved that EMG biofeedback of pelvic floor 1- Barnes, J., Bowman, E. and Cullen, J.: musculature is an effective approach to vulvar "Biofeedback as an adjunct to psychotherapy vestibulitis and vaginismus. And they, added in the treatment of vaginismus", Biofeedback that EMG biofeedback for pelvic floor muscles Self-Regulation, 9(3): 12-23, 2004. is important for decreasing pain and muscle 2- Basson, R., Althof, S., Davis, S., Fugl-Meyer, spasm in cases suffering from hypertonicity of K., Goldstein, I., Leiblum, S., Meston, C., Rosen, R. and Wagner, G.: "Summary of the the pelvic floor musculature. Recommendations on Sexual Dysfunctions in And, the results of this study confirmed 35 women", J. Sex. Med., 1(1): 24–34, 2004. with that of Wells, who proved that 3- Benson, H.: "Relaxation techniques. A physiotherapy treatment can help to relax the practical handbook for the health care pelvic floor muscles, which resulting in a professional. Churchil living stone", decrease of pain. And so, comfortable sexual Edinburgh, 3-11, 1995. intimacy becomes possible. 4- Bergeron, S., Binik, Y.M., Khalife, S., Pagidas, In dealing with patients number 10 and K., Glazer, H., Meana, M. and Amsel, R.: "A number 15, they have been married from 7 and randomized comparioson of group cognitive- 6 months ago respectively and they tried all behavioral therapy, surface electro myographic kinds of psychotherapy, medical therapy and biofeedback, and vestibulectomy in the treatment of dyspareunia from vulvar sexual therapy. So, it was very difficult to vestibulitis", Pain, 91: 297-306, 2001. convince them to start the treatment sessions 5- Bergeron, S. and Josée Lord, M.: "The but once, they instructed as well as, performed integration of pelvi-perineal re-education and relaxation training, and the lubricated vaginal cognitive behavioral therapy in the multi- electrode was introduced gradually and gently disciplinary treatment of the sexual pain inside their vagina, they got the confidence as disorders". Br. Association for sexual and well as, went through the treatment program relationship Therapy, 18(2): 135-141, 2003. and, they had successful painfree with

Bull. Fac. Ph. Th. Cairo Univ.,: Vol. 12, No. (1) Jan. 2007 135

6- Binik, Y., Bergeron, S. and Khalifr, S.: 19- Lantz, D.: "An overview in clinical Dyspareunia principles and practice of sex electrotherapy", J. Obstet. Gynecol., 103(5): therapy, 3rd Ed., New York, NY: The Guilford 56-68, 2003. press, 2000. 20- Lowenstin, E., Khalife, S. and Meana, M.: 7- Binik, Y., Berklay, K., Khalifr, S. and Meana, "Pelvic floor dysfunction", Am. J. Obstet. M.: "The sexual pain disorders". Ann. Rev. Sex Gynecol., 178(120): 67-89, 2004. Research, 16 (34): 210-235 ,1999. 21- Mc Kay, E., Glazer, H., Ksaufman, H., 8- Campbell, S.: Gynecology by ten teachers: Berkova, Z. and Redko, V.: "EMG psychological aspects of gynecology, Guilford biofeedback for the treatment of VVS", Am. press, New York, 2nd Ed., 245-267, 2000. Fam. Physician, 68(4): 337-342, 2001. 9- Clayton, A.H.: "Sexual function and 22- Paul, M., Evgeny, V., Bronya, V., Shout, L., dysfunction in women", Psychiatr. Clin. North Dwain, L., Robert, E., Weichung, J., Yong, L., Am., 26: 673-682, 2003. Tom, A., Kari, U. and Robert, M.: "Heart rate 10- De Kruiff, M.E., TEr Kuile, M.M., Wujenborg, variability biofeedback increases baroreflex P.M. and Van Lankveld, J.D.M.: "Vaginismus gain and peak expiratory folw", Psychosomat. and dyspareunia: is there difference in clinical Med., 65: 796-805, 2003. presentation?", J. Psychosomatic Obstet. 23- Payne, R.: Relaxation Techniques. A practical Gynecol., 21: 149-155, 2000. handbook for the health care professional, 11- Dominic, M.: "Prevalence and predictors of Churchill living stone, Edinburgh, 117-130, chronic lower genital tract discomfort", Am. J. 1995. Obstet. Gynecol., 85: 545-550, 2002. 24- Peter, C.: Basics and clinical aspects of 12- Glazer, H.I.: "Dysesthetic long- Obstetrics and Gynecology, 5th Ed., 56-99, term follow-up after treatment with surface 2004. electro myography - assisted pelvic floor 25- Phillips, N.: "Clinical evaluation of muscle rehabilitation", J. Reprod. Med., 45: dyspareunia", Int. J. Impot.; 10: 21-27, 1998. 798-802, 2005. 26- Reissing, E.D., Binik, J.M., Khalife, S., Cohen, 13- Glazer, H.I., Rodke, G., Swenciois, C., Hertz, D. and Amsel, R.: "Vaginal spasm, pain and R. and Young, A.W: "The treatment of vulvar behavior: An Empirical Investigation of the vestibgulitis syndrome by electro- myographic Diagnosis of Vaginismus", Arch. Sex. Behav., biofeedback of pelvic floor musculature", J. 33(1): 5-17, 2004. Reprod. Med., 40: 283-290, 1995. 27- Roger, M., Carren, W. and Dean, B.: Clinical 14- Graziottin, A.: "Etiology and diagnosis of Electrotherapy. Therapeutic uses of coital pain", J. Endocrinol. Invest., 26 (3 biofeedback, Rev. Med. Suisse, 3rd Ed., 489- suppl): 115-121, 2003. 523, 1999. 15- Heiman, J.R.: "Sexual dysfunction: overview 28- Rosenbam, T.: "Physical Therapy for of prevalence, etiological factors, and Vaginismus", J. Sex Marital Ther., 31(4): 349- treatment", J. Sex Res., 39: 73-78, 2002. 356, 2005. 16- John, D. and Brand, P.: "Treating vaginismus 29- Seo, J., Choe, J., Lee, W. and Kim, K.: with perry brand sensors", Am. Board of "Efficacy of functional electrical – biofeedback Sexology, 45(5): 23-34, 2001. with sexual congnitive – behavioral therapy as 17- Kim, S. and Kim, H.: "Effects of relaxation treatment of vaginismus", J. Urol., 66(1): 78- breathing exercise on anxiety, depression and 90, 2005. leukocyte in hemopoietic stem cell 30- Sims, M.J.: "On Vaginismus". Transcripts of transplantation patients", Cancer Nursing, the obstetrical society of London, 3: 356-367, 28(1): 79-83, 2005. 1861. 18- Lamont, J.A.: "Vaginismus, Am. J Obstet. Gynecol., 131: 632-636, 1978.

Bull. Fac. Ph. Th. Cairo Univ.,: Vol. 12, No. (1) Jan. 2007 136

31- Strong, G. and Antonio, W.: "Pain test book experienced threat in women with and without for therapist", Motereal Quebec, 3rd Ed., 129- vaginismus, Behav. Resear. Ther., 39: 395- 139, 2002. 408, 2001. 32- Van der velde, J. and Everaerd, W.: "Voluntary 34- Weijmar Schultz, W., Basson, R. and Binik, J.: control over pelvic floor muscles in women "Women's sexual pain and its management", J. with and without vaginismic reactions", Int. Sex. Med., 2: 301-316, 2005. Urogynecol. J., 10: 230-236, 1999. 35- Wells, J.: Pelvic Dysfunction Physical 33- Van der velde, J. and Everaerd, W.: "The Therapy, Mc-Graw Hill, New York, 2nd ed., relationship between involuntary pelvic floor 55-60, 2006. muscle activity, muscle awareness and

الملخص العربي

تأثير تمارين االسترخاء المدعمة بالتغذية الحيوية اإلسترجاعية ف يعالج التشنج المهبلي

تهدف هذه الدراسة إلى معرفة تأثير تمارين اإلسترخاء المدعمة بالتغذية الحيوية اإلسترجاعية ف يعالج التشنج المهبلي . وقد أجريت هذه الدراسة على عشرين سيدة متطوعة من حديثات الزواج ) 2-7 شهور( ، من العيادة الخارجية ألمراض النساء بمستشفى القصر العين ي الجامعي ، بعد أن تم تشخيصهن بأنهن تعانين من التشنج المهبل ياألولى ، وكانت أعمارهن تتراوح ما بين 25-35 عاما ًا. تم عالجهن بتمارين اإلسترخاء المدعمة بالتغذية الحيوية اإلسترجاعية ، بواقع جلستين أسبوعياًا لمدة ثالثة أسابيع، باإلضافة إلى برنامج منزل ي يوم ي . وقد تضمنت القياسات قياس شدة األلم الحالية، وقد تم قياسه بالمقياس المدرج لقياس شدة األلم الحالية ومقدار التشنج ف يعضالت الحوض الرافعة والتي تم قياسها بجهاز التغذية الحيوية اإلسترجاعية وذلك قبل بداية الدراسة وأيضاًا بعد االنتهاء من الجلسة العالجية السادسة . وقد أوضحت النتائج عن انخفاض ذو داللة معنوية عالية ف ي شدة األلم الحالية وأيضاًا مقدار التشنج ف يعضالت الحوض الرافعة ، وعليه يمكن أن نستخلص أن تمارين اإلسترخاء المدعمة بالتغذية الحيوية اإلسترجاعية تعد أحدى وسائل العالج الطبيعي الفعالة ف يعالج المريضات الالتي تعانين من التشنج المهبلي . الكلمات الدالة : التشنج المهبلي ، تمارين اإلسترخاء ، التغذية الحيوية اإلسترجاعية ، التشنج المهبل ياألولى .

Bull. Fac. Ph. Th. Cairo Univ.,: Vol. 12, No. (1) Jan. 2007