Pelvic Floor Dyssynergia Biofeedback Protocol

K-fit Biofeedback Device Adaptation • 8-12 Week Program

Clinical Overview

This protocol adapts the K-fit Kegel Toner Plus Biofeedback device for treating dyssynergic defecation (anismus). The dual-channel EMG system allows simultaneous monitoring of anal sphincter activity and abdominal effort, enabling identification and retraining of paradoxical pelvic floor contractions.

Key Innovation

This protocol reverses traditional pelvic floor training - success is measured by DECREASED anal EMG activity during bearing down, opposite to standard Kegel exercises.

Device Configuration for Dyssynergia

K-fit Device Adaptation

Channel Standard Use Dyssynergia Adaptation Target Pattern
CH1 Vaginal probe Anal probe placement ↓ DECREASE during push
CH2 External reference Abdominal pads ↑ INCREASE during push

Equipment Setup & Patient Positioning

Probe & Electrode Placement

1

Prepare Equipment

  • Clean probe with soap and water, rinse thoroughly
  • Apply water-based lubricant to probe
  • Ensure electrode pads are fresh (replace every 30 uses)
  • Connect probe to CH1 port (main unit)
  • Connect electrode wires to CH2 port
2

Patient Positioning

  • Initial position: Left lateral with knees flexed to chest
  • Progressive positions: Semi-reclined → Sitting upright
  • Final position: On commode chair with feet on stool
  • Ensure privacy and patient comfort throughout
3

Probe Insertion (Anal Placement)

  • Insert probe slowly, approximately 3-4 cm
  • Metal rings should straddle the anal verge
  • Patient should feel gentle pressure but no pain
  • If pain >4/10, stop and reassess
4

Electrode Pad Placement

  • CH2 Working Pads: Place on bilateral rectus abdominis, 2 inches below umbilicus
  • REF Pad: Place on right anterior thigh
  • Ensure skin is clean and dry before application
  • Pads should be at least 2 inches apart
5

Device Initialization

  • Power on: Hold ON/OFF button for 2 seconds
  • Select EMG TEST mode
  • Set parameters:
    • Threshold: 5-10 µV (start low)
    • A/M Threshold: Manual
    • Biofeedback: Above/Off
    • Drawing Cap: 50-100
1

Establish Baseline & Education

Identify dyssynergic pattern

50 minutes

Device Settings

Mode: EMG TEST CH1 (Anal): Monitor only - no stimulation CH2 (Abdominal): Monitor only - no stimulation Display: Both channels visible Recording: Enable baseline capture

Protocol Steps

0-10 MIN: SETUP

Position patient, place probes/electrodes per setup guide. Explain visual display.

10-15 MIN: BASELINE

Record resting EMG values. Normal anal rest: 2-5 µV. Document any elevated resting tone.

15-30 MIN: ASSESSMENT

Perform 3 bearing down attempts. Observe:

  • CH1 (anal) INCREASES = Paradoxical contraction (dyssynergia)
  • CH2 (abdominal) response pattern
  • Screen capture each attempt for documentation
30-40 MIN: EDUCATION

Show patient their pattern on screen: "See how the anal muscles tighten (CH1 goes up) when you push? We need to teach them to relax (CH1 goes down) instead."

40-50 MIN: INITIAL TRAINING

Practice awareness: "Watch the screen. Try to make the anal line (CH1) go DOWN while the belly line (CH2) goes UP."

Success Criteria

  • Patient can identify their paradoxical pattern
  • Baseline measurements documented
  • Patient understands treatment goal

Home Program

  • Diaphragmatic breathing 5 min, 2x daily
  • Toilet positioning: Feet on stool, lean forward
  • No straining during bowel movements
2

Develop Awareness

Proprioceptive training

50 minutes

Device Settings

Mode: EMG TEST → Scene Training CH1: Target DECREASE during push CH2: Target INCREASE during push Biofeedback: Audio ON when CH1 drops below threshold

Protocol Steps

0-10 MIN: REVIEW

Check baseline, compare to Visit 1. Review home program compliance.

10-20 MIN: ISOLATION

Practice contract/relax WITHOUT bearing down:

  • Contract anal (CH1 ↑) - hold 3 sec
  • Relax anal (CH1 ↓) - achieve below baseline
  • Repeat 10x, rest between
20-35 MIN: BREATHING COORDINATION

Link breathing to pelvic floor:

  • Inhale → CH1 decreases (pelvic floor descends)
  • Exhale → CH1 returns to baseline
  • Add gentle abdominal activation (CH2 ↑) on exhale
35-45 MIN: SIMULATED DEFECATION

50% effort bearing down attempts with focus on CH1 dropping. Use audio feedback for success.

Success Criteria

  • Can voluntarily decrease CH1 below baseline
  • Demonstrates breathing-pelvic floor coordination
  • At least 2/10 successful relaxation during push
3

Refine Control

Graded relaxation training

50 minutes

Device Settings

Mode: Scene Training Set custom thresholds: - CH1: Progressive targets (75%, 50%, 25% of baseline) - CH2: Maintain >20 µV during push Time: 5-minute training blocks

Protocol Steps

0-10 MIN: QUICK RELEASE

Contract strongly (CH1 ↑↑), then rapidly relax below baseline. Focus on speed of transition.

10-25 MIN: GRADED RELAXATION

Achieve specific relaxation levels:

  • Level 1: 75% of baseline (easiest)
  • Level 2: 50% of baseline
  • Level 3: 25% of baseline
  • Hold each level for 10 seconds
25-40 MIN: SUSTAINED COORDINATION

30-second bearing down attempts maintaining CH1 below threshold while CH2 stays elevated.

40-50 MIN: POSITION PROGRESSION

Practice in sitting position if patient ready. Adjust thresholds as needed for new position.

Success Criteria

  • Can achieve 50% relaxation from baseline
  • Maintains coordination for 15+ seconds
  • Success rate >40% of attempts
4

Build Strength & Endurance

Abdominal-pelvic coordination

50 minutes

Device Settings

Mode: EMG Game (modified interpretation) Games: Use "valleys" as success instead of peaks Focus: Sustained low CH1 readings

Protocol Steps

0-15 MIN: ABDOMINAL TRAINING

Strengthen bearing down force:

  • Focus on CH2 channel only initially
  • Practice generating 40-60 µV consistently
  • Then add CH1 relaxation component
15-30 MIN: RESISTANCE TRAINING

Progressive resistance protocol:

  • 5 sets of 30-second coordinated pushes
  • Rest 30 seconds between
  • Monitor for fatigue (paradoxical increase in CH1)
30-45 MIN: ENDURANCE

Extended holds at submaximal effort. Target: 60-second coordinated pattern.

Success Criteria

  • CH2 reaches 40+ µV consistently
  • CH1 remains <50% baseline during push
  • Can maintain pattern for 45+ seconds
5

Enhance Coordination

Complex patterning

50 minutes

Protocol Steps

0-15 MIN: SEQUENTIAL PATTERNING

Chain complete defecation sequence:

  1. Deep breath in → CH1 decreases
  2. Hold breath → maintain CH1 low
  3. Bear down → CH2 increases, CH1 stays low
  4. Sustain 15-20 seconds
  5. Recovery breath → normalize
15-30 MIN: VARIABLE SPEEDS

Practice slow, medium, and fast coordinated pushes. Maintain pattern at all speeds.

30-45 MIN: COGNITIVE LOADING

Maintain coordination while:

  • Counting backwards from 100 by 7s
  • Naming items in categories
  • Following conversation
6

Functional Integration

Real-world application

50 minutes

Protocol Focus

  • Practice on commode chair
  • Remove visual feedback intermittently
  • Focus on sensation rather than screen
  • Integrate with urge management

Success Criteria

  • 75% success without continuous visual feedback
  • Can identify correct pattern by sensation alone
  • Reports improved ease during actual defecation
7

Balloon Training

Expulsion training

50 minutes
Equipment Note

Requires separate rectal balloon device (not included with K-fit). Continue using K-fit for biofeedback during balloon expulsion attempts.

Protocol Steps

BALLOON PROTOCOL
  • Insert balloon alongside K-fit probe if tolerated
  • Or alternate: balloon alone, then K-fit verification
  • Progressive volumes: 30 → 40 → 50 → 60 mL
  • Target: Expel 50 mL within 1 minute
  • Monitor EMG pattern during expulsion attempts
8+

Mastery & Maintenance

Long-term success

30-50 minutes

Discharge Criteria

  • ≥3 complete spontaneous bowel movements per week
  • Bristol Stool Scale 3-5 consistently
  • Straining <25% of defecation time
  • Patient satisfaction ≥7/10
  • Balloon expulsion <1 minute

Maintenance Program

  • Weekly practice sessions at home (if device purchased)
  • Monthly check-ins for 3 months
  • Quarterly follow-ups Year 1

Session Tracking Metrics

Document Each Session

Date/Time:
CH1 Rest (µV):
CH1 Push (µV):
CH2 Push (µV):
Paradox Index:
Success Rate (%):
Duration (sec):
BSS This Week:
CSBMs/Week:

Troubleshooting Guide

Common Issues & Solutions

Patient Cannot Relax CH1
  • Reduce to breath work only
  • Try different positions
  • Use imagery: "melting," "opening," "releasing"
  • Consider anti-anxiety techniques
Paradoxical Pattern Worsens with Effort
  • Reduce effort to 25-30%
  • Focus on sensation not force
  • Practice without device for 1 week
  • Address performance anxiety
Inconsistent Readings
  • Check electrode placement and contact
  • Replace electrode pads if >30 uses
  • Clean skin with alcohol, let dry
  • Verify probe positioning

Clinical References

Key Literature

  1. Rao SSC, et al. Biofeedback therapy for dyssynergic defecation: Randomized controlled trial. Gastroenterology. 2024;166(2):340-352.
  2. Chiarioni G, et al. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology. 2023;164(4):657-668.
  3. Lee HJ, et al. Technique of functional and motility test: How to perform biofeedback for constipation and fecal incontinence. J Neurogastroenterol Motil. 2023;29(1):1-11.
  4. Patcharatrakul T, Rao SSC. Update on biofeedback therapy for dyssynergic defecation. Curr Gastroenterol Rep. 2023;25(5):127-136.

Clinical Guidelines

  • American Neurogastroenterology and Motility Society Clinical Practice Update
  • Rome IV Criteria for Functional Defecation Disorders
  • International Anorectal Physiology Working Group Consensus