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 Stimulation Techniques 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

Intra Vaginal Stimulation Dehghan FM,PT,Ph.D

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 Demand Heart Pacemakers Pregnancy Post Volume Residual over 100ml Obstruction of the urethra Bleeding Urinary tract infection or Vaginal discharge Complete peripheral denervation of pelvic floor 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 Awareness of the pelvic floor musculature Muscle strengthening Reflex or automatic contraction 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

Extracorporeal Magnetic Innervations (ExMI) Dehghan FM,PT,Ph.D