In The Name Of God

Electrotherapy Methods in Pelvic Floor DisordersAfsaneh Dadarkhah M.S of Pt

Electrotherapy MethodsElectrical Stimulation Biofeedback TherapyElectromagnetic Stimulation Therapy

Electrical Stimulation(E.S)

Electrical Stimulation History1952: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 StimulationTechniquesLong term (chronic , weak) E.SShort term (acute , strong) E.SAcute Maximal Functional E.SMaximum 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 PulsesMonophasic Square PulsesBiphasic Square PulsesMonophasic Coupled spike Pulses

To Minimize Electrochemical ReactionElectrode-mucosa interface , biphasic or alternating pulsesSmall electrodes & high charge densitiesLow frequencyBidirectional pulses

Frequency of E.S in IncontinenceLow Frequency (5-10 Hz) SustainedHigh Frequency (20-50 Hz)Slow Twitch muscle fiber fires at 10-20 HzFast Twitch muscle fiber fires at 30-60 HzCurrent Frequencies greater than 40 Hz induce fatigueFrequencies of approximately 30 Hz induce tetanized smooth contractionThe Best frequency: Frequencies about 10-40 Hz in 250-500msec activate fast & slow twitch fibers

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

Duty CycleRatio of stimulus time to rest timeTypical Duty Cycle: 1/2Weakness or neurological impairment:1/3

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

Other Methods of E.SFaradism: Maximal stimulus & short burstsInterferential 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 activitySurface 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 FloorVaginal ChildbirthOther Pelvic TraumaSurgeryAging

Pudendal nerve latency is prolonged by vaginal delivery , vaginal surgery for prolapse.To improve urethral closure innervation of the pelvic floor must existNo 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 PracticeDifferent Type of E.S 1) Office Therapy 2) Home Treatment Program

Dehghan FM,PT,Ph.D*Intra Vaginal Stimulation

Dehghan FM,PT,Ph.D

Different Available ProbesStandard two-ring vaginal probeTampon two-ring vaginal probeInflatable intravaginal probeIntraanal probeDisposable probeTwo-channel vaginal & anal insertion probe

Special Conditions that Affect the Choice of ProbeVaginal Size (depth 4-12 cm) & shapeVaginal angle (10-40 degree) & quality of the levator ani (thin or thick fibers)Type & degree of vaginal wall descent

Home Treatment ProgramLow frequency (10-20Hz) Urge incontinence High frequency (35-50Hz) Stress incontinence

Selection of PatientsUrinary incontinence & Pelvic floor dysfunctionUnsuccessful P.F.M training as a first line treatment

The Main Contraindications of E.SDemand Heart PacemakersPregnancyPost Volume Residual over 100mlObstruction of the urethraBleedingUrinary tract infection or Vaginal dischargeComplete peripheral denervation of pelvic floorSever genital prolapse with complete eversion of the vagina

Mild & Moderate Incontinence are the best candidates

Clinical ResultsOverall Cure rates50% is commonNo morbidityNo side effects20 minutes of maximal stimulation6 months low intensity (10Hz) with vaginal electrodes

The Results in the protocolsPost-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 monthsType 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.BE.M.GManometryThermal measurementE.E.GElectro dermal feed backRespiration rate

B.F.B in IncontinenceE.M.GPressure 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 disordersDetrusor InstabilityDetrusor Sphincter dyssynergiaEnuresis

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

B.F.B MethodsCystometric B.F.BPelvic floor muscle B.F.B

B.F.B TechniqueAwareness of the pelvic floor musculatureMuscle strengtheningReflex or automatic contractionUse of new skills in activity of daily life (ADL)

Clinical ResultsWith bladder BFBWith Pelvic floor muscle training With Lower urinary tract symptomsWith Detrusor-sphincter dyssynergia

Electromagnetic Stimulation Therapy

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

Dehghan FM,PT,Ph.D