1. In The Name Of God

2. Electrotherapy Methods in Pelvic Floor Disorders
Afsaneh Dadarkhah M.S of Pt

3. Electrotherapy Methods
Electrical Stimulation
Biofeedback Therapy
Electromagnetic Stimulation Therapy

4. Electrical Stimulation (E.S)

5. 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.

6. 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

7. Basic Principals & Mechanism of E.S

8. 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 )urethral sphincteric mechanism )Levator ani muscles )External anal sphincter

12. 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

13. E.S Pulse Wave Forms Biphasic Coupled Pulses Monophasic Square Pulses
Biphasic Square Pulses
Monophasic Coupled spike Pulses

20. To Minimize Electrochemical Reaction
Electrode-mucosa interface , biphasic or alternating pulses
Small electrodes & high charge densities
Low frequency
Bidirectional pulses

21. Frequency of E.S in Incontinence
Low Frequency (5-10 Hz) Sustained
High Frequency (20-50 Hz)
Slow Twitch muscle fiber fires at Hz
Fast Twitch muscle fiber fires at Hz
Current Frequencies greater than 40 Hz induce fatigue
Frequencies of approximately 30 Hz induce tetanized smooth contraction
The Best frequency: Frequencies about Hz in msec activate fast & slow twitch fibers

22. 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)

23. Duty Cycle Ratio of stimulus time to rest time Typical Duty Cycle: 1/2
Weakness or neurological impairment:1/3

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

25. 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 )Bipolar technique )Four electrodes technique

28. 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

31. Causes of Denervation of the Pelvic Floor
Vaginal Childbirth
Other Pelvic Trauma
Surgery
Aging

32. 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

33. Clinical Practice
Different Type of E.S ) Office Therapy ) Home Treatment Program

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

38. 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

48. 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

49. Home Treatment Program
Low frequency (10-20Hz) Urge incontinence
High frequency (35-50Hz) Stress incontinence

50. Selection of Patients Urinary incontinence & Pelvic floor dysfunction
Unsuccessful P.F.M training as a first line treatment

51. 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

52. Mild & Moderate Incontinence are the best candidates

53. 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

54. 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/ msec)
Duration of treatment : 20 minutes (several monthes),10sesstions until 6 months
Type of current waveform (alternative & rectangular biphasic)

55. Bio Feedback Therapy

56. 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.

57. The Most Modalities of B.F.B
E.M.G
Manometry
Thermal measurement
E.E.G
Electro dermal feed back
Respiration rate

58. 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

59. Uses of B.F.B in Urologic disorders
Detrusor Instability
Detrusor Sphincter dyssynergia
Enuresis

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

61. B.F.B Methods
Cystometric B.F.B
Pelvic floor muscle B.F.B

71. 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)

78. Clinical Results With bladder BFB With Pelvic floor muscle training
With Lower urinary tract symptoms
With Detrusor-sphincter dyssynergia

79. Electromagnetic Stimulation Therapy

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