In The Name Of God
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)