Discussion of this article is open. Please post comments below.
Reason
for choosing article: I strongly believe in NMES/TENS for pelvic floor rehab.
I use NMES on 80% of patients with PF dysfunctions,
especially bladder control problems. I have had truly miraculous results with
NMES on some patients (case report presented at CSM 2007). I met the author at
ICS and was so excited that he was putting this info out to support clinical
decision making.
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Electrical stimulation (ES) has been used over several
decades in the treatment of various lower urinary tract dysfunctions.
·
The S2-S4 nerve roots provide the principle motor supply to
the bladder. Specifically the S3 root mainly innervates the detrusor muscle and
is the main target of sacral neuromodulation.
·
Neuromodulation
may be defined as affecting a nerve with stimulation or medication in order to
directly impact the other nerves regulated by that nerve(?)
·
Posterior tibial nerve (PTN) is a mixed nerve containing
L5-S3 fibers, originating again from the same spinal segments as the
parasympathetic innervations to the bladder (S2-S4) is a well established sit
for stimulation to the bladder
o
A commercial device (Urgent-PC, Uroplasty, Inc.,
Minnetonka, USA) uses PTNS over 12 sessions of the percutaneous posterior
tibial nerve stimulation (PTNS), at weekly intervals. RCT showed significant
improvement in overall OAB symptoms (60/110) compare to sham (23/110). It was
shown that PTNS responders can continue to benefit from the therapy over 12
months.
Methods:
·
This review considers only non-invasive ES techniques,
defined as “a procedure which does not involve introduction of an instrument
into the body”; no needles, no intra-vaginal nor intra-anal electrodes; transcutaneous
electrical nerve stimulation (TENS) was defined as a technique where the
electrical stimuli are passed through the intact skin
·
Authors searched the electronic database PubMed
from inception until December 2013. Search terms used were “urge incontinence”,
“urgency”, “overactive bladder”, “urinary incontinence” or “detrusor
instability” in combination with “electrical stimulation”, “TENS”,
“transcutaneous electrical nerve stimulation”, “nerve stimulation”, “surface neuromodulation”,
“non-invasive stimulation”, “trial” or “study”. In addition, we followed
citations from the primary references to relevant articles which the database could
not locate.
·
Exclusion criteria were: studies which were not
in English; studies of fecal incontinence treatment; those involving children,
those studying animal models; those involving percutaneous electrical
stimulation, anal stimulation, vaginal/penile stimulation or implanted devices
or those not primarily focused on storage symptoms. A flow diagram of the
selection process is shown in Fig. 1.
·
The primary search identified 410 articles. Using the defined
exclusion criteria authors reviewed in detail 16 articles; populations were widely
heterogeneous
Sacral
stimulation Electrode placement:
·
Peri-anal S2-S3 dermatomes 3 studies showed improvement =
reduction in detrusor over activity, parameters varied: 12 h/day, 6 h/day,
·
Over sacral foramina , 2x/day x 15 min
Tibial Posterior Tibial Nerve
Stimulation
·
Initially
developed using the SANS (Stoller afferent nerve stimulator) 34 gauge needle
electrode in SP6 acupuncture point and surface elect rode placed behind medial
malellelus
·
Non-implanted
electrodes are placed the above medial
malleolus and at medial aspect of calcaneus
·
Studies show
promising results, 1 shows good acceptance of use of device at home
Suprapubic- study to reduce pain in PBS also showed
decr urinary frequency, efficacy for use in OAB is unproven
Are the acute effects of
stimulation of clinical significance?
·
Researchers
have tried to answer this by assessing the immediate effects of ES during a
urodynamic study
·
A study on
SCI patients receiving ES to thigh showed Increased maximum cystometry capacity
MCC and decreased maximum detrusor pressure MDP, improved continence
·
A study on
ES over S3 dermatome did not clearly demonstrated effects on MCC, but improved
decrease in MDP
·
Studies in
neurologic patients 50% improvement in MCC, other studies no sig difference
Which stimulation parameters?
·
The location of electrodes and
range of stimulus parameters are likely to be critical factors in all forms of
stimulation.
·
Relevant stimulus parameters
include pulse width; pulse repetition frequency; burst length (if applicable)
and stimulus intensity (preferably quoted as current as voltage stimulation
coupled with uncertain electrode-tissue interface impedance leads to
uncertainty as to delivered stimulus strength). The technical description of
the stimuli used in some studies does not give all these details.
·
Stimulus intensity in question-
below motor threshold? Above perception threshold? To anal wink?
·
Sham ES is difficult to produce 2
to sensation
·
One method : Habituation as sham-
tell the pt that they are getting used to stim then turn intensity to 0
·
One study did not tell
participants that them may receive sham stim- ethical?
Conclusion: The current consensus is that
the most promising site of stimulation is the S3 area of the spinal cord over
the sacral region or over the posterior tibial nerve, but it is not clear which
approach to stimulus delivery is the most effective. Little is known about the
underlying mechanisms of action and which exact structures need to be
stimulated.
Questions for discussion:
·
How often do you use TENS/NMES?
·
What parameters?
·
Do you issue units for home use?
·
What are barriers to using TENS?
·
What are best results?
I use TENS very often for pain starting with 100 Hz, continuous, 2 hrs on 2 hrs off and modify from there. I like Cindy's idea of placing electrodes near the ischiorectal fossa to access the pudendal nerve. Would love to hear what parameters others use.
ReplyDeleteI use Unilateral TTNS with 15 Hz 260 uSec PW 1.25 diameter electrode posterior to medial malleolus and second on medial calcaneus. 30 min 1-7 weekly if a home unit is purchased. Intensity to unpleasant but tolerable.
ReplyDeleteI am just starting to use IFC for slow colonic transit. 4000Hz carrier frequency 4004-4010 sweep, Zynex unit. I used 2x3 inch electrodes on anterior surface of LLQ. Patient loved it. Felt like a massage to her abdomen. We have been doing TTNS, abdominal massage and trunk mobility exercise which altered her gastric transit time in ascending and transverse colon. Hopefully this will get the descending colon going. She is considering a sigmoidectomy.
Sandra Gallegher