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
36
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)
High frequency (35-50Hz)
Urge incontinence
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.
2.
3.
4.
5.
6.
7.
8.
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
1. Awareness of the pelvic floor musculature
2. Muscle strengthening
3. Reflex or automatic contraction
4. Use of new skills in activity of daily life (ADL)
Clinical Results
With
With
With
With
bladder BFB
Pelvic floor muscle training
Lower urinary tract symptoms
Detrusor-sphincter dyssynergia
Electromagnetic Stimulation
Therapy
Extracorporeal Magnetic
Innervations (ExMI)
Dehghan FM,PT,Ph.D
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