Vol. 15 Issue 26
A guide to general principles, categories and use for pelvic floor rehabilitation
In 46 A.D., Scribonius Largus used electric eels to alter the symptoms of chronic headache and gout, supporting the fact that electricity can be conducted through living tissues to influence physiologic states.1
In 76 A.D., Discorides expanded electricity's treatment options to the pelvic floor by using it to treat hemorrhoids and prolapse.1 In the 1700s, Luigi Galvani described the link between electric shocks and muscle contractions in frogs' legs.2
Throughout the late 19th and 20th centuries, published articles suggested using electrical stimulation to "increase bladder strength and reduce dribbling," and "improve incontinence after childbirth."
As this literature suggests, appropriate use of e-stim can facilitate a pelvic floor rehabilitation program. Specifically, e-stim often provides neuromuscular reeducation for patients with weak pelvic floor muscles (PFM) or for patients who cannot contract them at all.3-6 Electrical stimulation is also used for reflex inhibition of premature bladder contractions. Since current clinical units stimulate intact peripheral nerves,7 eliciting a muscle response with stimulation indicates that the muscle is all or partially innervated. This treatment may enable patients to re-establish neural pathways and actively contract their PFM again.
While there are no specific protocols for e-stim on patients with pelvic floor dysfunction, the literature documents its success in treating reflex detrusor inhibition in patients with urgency/frequency.8-10
Dedicated e-stim units for pelvic floor applications are FDA approved and therefore all pelvic floor stimulators must have similar parameters.
As electrical stimulation and biofeedback treatment options have become more widely used, more manufacturers sell dual purpose electrodes that can be used for stimulation and biofeedback. In some newer systems, e-stim and biofeedback capabilities are combined in a single clinical unit and come with a variety of pre-programmed treatment protocols.
As with peripheral stimulation, the shape, size and placement of electrodes affects current density and what the patient feels.11 Intimate contact with nerve endings in the skin is a principal that applies whether electrodes are on the skin surface or within the rectal or vaginal canal. The pelvic floor electrode must fit snugly or stay in place in the orifice.12-14
Other E-Stim Technology
Additional technology involving electrical stimulation can help treat various conditions. The following three are typically in physicians' domains.
Sacral nerve root stimulation,2 also known as sacral neuromodulation, is used for improving urinary frequency and urgency in the absence of bladder outlet obstruction.15,16 It is also being used for the symptoms of fecal incontinence, pelvic pain and interstitial cystitis (IC).17,18 The effects of sacral nerve root stimulation are observed during a trial period where a urologist implants electrodes (percutaneously) in S 2-3 nerve roots. Modulation of nerve responses and restoration of more normal reflex control of bladder function is assessed. If results are good with the percutaneous trial, the device can be surgically implanted.
Posterior tibial nerve stimulation19 is used for urge incontinence, overactive bladder and irritative voiding syndromes.20 It is also used for certain patients with IC and prostatitis.21 During this treatment, a physician inserts a fine needle electrode in the lower leg, to stimulate the posterior tibial nerve. Svihra et al suggested that effective, non-invasive treatment could be administered by applying a surface electrode on the posterior tibial nerve at the same spot.22
Magnetic stimulation. Extra corporeal magnetic stimulation, is based on the theory that muscular contractions can be induced by the application of a time-variable magnetic field via a magnet installed in the seat of the treatment chair. Treatments are based on specific stimulation protocols to help alleviate stress and urge incontinence.23,24
To enable the appropriate use of electrical stimulation, from an evidence-based perspective, therapists should explore and document more of e-stim's treatment options and specific effects on pelvic muscle strengthening.
References are available online at www.advanceweb.com/pt.
Jane Frahm is coordinator of women's health rehabilitation for the Rehabilitation Institute of Michigan in Detroit.