In The Name Of God

Electrotherapy Methods in Pelvic Floor

Disorders

Afsaneh Dadarkhah M.S of Pt

Electrotherapy Methods

Electrical Stimulation Biofeedback Therapy Electromagnetic Stimulation

Therapy

Electrical Stimulation

(E.S)

Electrical Stimulation History 1952:Bors described the influence of E.S on

the pudendal nerves. 1963:Caldwell developed electrodes that were

permanently implanted into the pelvic floor & controlled by radiofrequency.

1976:Suhel provided new methods for no implantable prineal stimulation.

1991:Godec & associates first described the use of no implanted stimulators specifically for bladder inhibition.

Electrical StimulationTechniques

Long term (chronic , weak) E.S Short term (acute , strong) E.S Acute Maximal Functional E.S Maximum Pelvic Floor E.S

Basic Principals & Mechanism of E.S

Electrical Stimulation is an effective treatment for stress incontinence and urge incontinanence.

This technique uses natural pathways and micturation reflexes.

E.S is commonly used to improve function of 1)urethral sphincteric mechanism 2)Levator ani muscles 3)External anal sphincter

E.S increases the number & strength of slow-twitch fibers, improving resting urethral closure.

E.S restore the inhibition effect (urge incontinence)

E.S increases the bulk of the levator ani muscle & the proportion of fast-twitch fibers & thus the ability of muscles to respond to a sudden increase in intra abdominal pressure

E.S Pulse Wave Forms

Biphasic Coupled Pulses Monophasic Square Pulses Biphasic Square Pulses Monophasic Coupled spike Pulses

To Minimize Electrochemical Reaction

Electrode-mucosa interface , biphasic or alternating pulses

Small electrodes & high charge densities

Low frequency Bidirectional pulses

Frequency of E.S in Incontinence

Low Frequency (5-10 Hz) Sustained High Frequency (20-50 Hz) Slow Twitch muscle fiber fires at 10-20 Hz Fast Twitch muscle fiber fires at 30-60 Hz Current Frequencies greater than 40 Hz

induce fatigue Frequencies of approximately 30 Hz induce

tetanized smooth contraction The Best frequency: Frequencies about 10-

40 Hz in 250-500msec activate fast & slow twitch fibers

Chronic Stimulation

Chronic stimulation (30 days) may increase the relative number of slow twitch fibers.(Probably by helping to transform fast twitch fiber to slow unit)

Duty Cycle

Ratio of stimulus time to rest time Typical Duty Cycle: 1/2 Weakness or neurological

impairment:1/3

Conventional E.S

Conventional E.S is applied to limit and avoid discomfort and muscle fatigue

Other Methods of E.S

Faradism: Maximal stimulus & short bursts

Interferential Therapy: Two interfering medium-frequency that product low frequency stimulation in the area of interest 1)Bipolar technique 2)Four electrodes technique

Transcutaneus Electrical Nerve Stimulation (TENS)

Transcutaneus electrical Nerve Stimulation of acupuncture points may be used to inhibit detrusor activity

Surface electrodes are placed bilaterally over both tibial nerves or both common proneal nerves. (5cm over the medial malleous).

Parameters: Intensity:5-8 v Frequency:2-10Hz Pulse width:5-20msec

Causes of Denervation of the Pelvic Floor

Vaginal Childbirth Other Pelvic Trauma Surgery Aging

Pudendal nerve latency is prolonged by vaginal delivery , vaginal surgery for prolapse.

To improve urethral closure innervation of the pelvic floor must exist

No effect can be expected in patients with complete lower motor neuron lesions.

After denervation injury E.S used to recondition muscle & facilitate sprouting of surviving motor axons

Clinical Practice

Different Type of E.S 1) Office Therapy 2) Home Treatment Program

Dehghan FM,PT,Ph.D 36

Intra Vaginal Stimulation

Different Available Probes

Standard two-ring vaginal probe Tampon two-ring vaginal probe Inflatable intravaginal probe Intraanal probe Disposable probe Two-channel vaginal & anal insertion

probe

Special Conditions that Affect the Choice of Probe

Vaginal Size (depth 4-12 cm) & shape Vaginal angle (10-40 degree) & quality

of the levator ani (thin or thick fibers) Type & degree of vaginal wall descent

Home Treatment Program

Low frequency (10-20Hz) Urge incontinence

High frequency (35-50Hz) Stress incontinence

Selection of Patients

Urinary incontinence & Pelvic floor dysfunction

Unsuccessful P.F.M training as a first line treatment

The Main Contraindications of E.S

1. Demand Heart Pacemakers2. Pregnancy3. Post Volume Residual over 100ml4. Obstruction of the urethra5. Bleeding6. Urinary tract infection or Vaginal discharge7. Complete peripheral denervation of pelvic

floor8. Sever genital prolapse with complete

eversion of the vagina

Mild & Moderate Incontinence are the best

candidates

Clinical Results

Overall Cure rates50% is common No morbidity No side effects 20 minutes of maximal stimulation 6 months low intensity (10Hz) with

vaginal electrodes

The Results in the protocols

Post-treatment follow up & drop up of 6 weeks to 7 years (self assessment & voiding diary urodynamic evaluation)

Frequency (20-50 Hz) Pulse width (0/08-100 msec) Duration of treatment : 20 minutes

(several monthes),10sesstions until 6 months

Type of current waveform (alternative & rectangular biphasic)

Bio Feedback Therapy

Bio feed back therapy

Biofeedback can be defined as the use of monitoring equipment to measure internal physiological events or various body conditions of which the person is usually unaware to develop conscious control of body amplify internal physiological response.

The Most Modalities of B.F.B

E.M.G Manometry Thermal measurement E.E.G Electro dermal feed back Respiration rate

B.F.B in Incontinence

E.M.G Pressure Sensors

These are applied to detect & measure the activity of anal or urinary sphincters & pelvic floor muscles & bladder control

Uses of B.F.B in Urologic disorders

Detrusor Instability Detrusor Sphincter dyssynergia Enuresis

A Major Reason for interest in BFB is the patient actively involved in treatment.

B.F.B Methods

Cystometric B.F.B Pelvic floor muscle B.F.B

B.F.B Technique

1. Awareness of the pelvic floor musculature

2. Muscle strengthening3. Reflex or automatic contraction4. Use of new skills in activity of daily life

(ADL)

Clinical Results

With bladder BFB With Pelvic floor muscle training With Lower urinary tract

symptoms With Detrusor-sphincter

dyssynergia

Electromagnetic Stimulation Therapy

Dehghan FM,PT,Ph.D 81

Extracorporeal Magnetic Innervations (ExMI)