Therapeutic methods for pelvic floor rehabilitation - N° 2

Suite article N° 2

3- Physiotherapy

3-1: neuromuscular electric stimulation
3-2: biofeedback training.

3-1 Therapeutic aspects of intra vaginal stimulation

    The position of vaginal or anal electrodes is very important. With vaginal electrodes it has been demonstrated that there is correlation between position and maximum urethral closing pressure (MUCP) if the electrode is on the muscle during stimulation. The best responses are obtained with electrodes in close proximity to the voluntary muscles of the pelvic floor (PC – IC) and to the pudendal nerves. The contractile response is always greatest when the electrodes are in close contact with the musculature of the levator ani.
    The surface of the electrodes should be sufficient to allow an effective action with a minimal loss of electrical activity. We consider, for vagina, 5 mm2 is the smallest to be effective. Ideally 15 mm2 should be used bearing in mind the width of the muscle branches. For anal stimulation 10 mm2 are sufficient.
    The shape of the electrodes is also important: too large electrodes (like bars) aren’t necessary the best, covering too much the muscle zone.

Effect of Functional Electrical Stimulation - FES

Electric parameters are those recommended by the Northern school: M. Fall, Erlandson, Carlsson, Sundin & Eriksenn.

In both intra-vaginal or anal stimulation, we know that neuromuscular stimulation of pelvic floor musculature – low frequency biphasic stimulation zero net D.C. – both inhibits the bladder in urge incontinence, and increases the urethral pressure profile in genuine stress incontinence, by reflex action, depending on the frequency used.

-    Stress incontinence :  50 Hz
-    Urge incontinence (bladder inhibition) : 10Hz
-    Mixed incontinence : 20 Hz or double associated stimulation 5O Hz – 20 Hz

Interferential technique may be also used with alternating pulse using 3.000 / 4.000 Hz modulated 5 - 10 Hz for urge incontinence, and 3.000 / 4.000 Hz modulated 50 - 70 Hz for stress incontinence.

Other side effects of the FES are:
    to increase of the strength of the pelvic floor muscle
    to improve the urethral sphincter response
    to involve an element of conditioning
    to reduce and/or cure PF pain such as dyspareunia

Contra indications - when not to use F.E.S.

One has to indicate some contra-indications:
    during pregnancy or if the chance of pregnancy exists
    during menstrual period ( it is mainly a psychological contra-indication )
    when there are symptoms of urinary tract infection or vaginal infection
    when there are symptoms of atonic bladder ( because of high compliance ), urinary retention, uretheral reflux
    demand pace maker
    cancer
    total denervation
    non menstrual bleeding
    exteriorised hysterocele

The coil is not a contra-indication because we use biphasic wave with zero DC


3-2 General biofeedback therapy

Biofeedback therapy has different objectives:
1-     to identify the pelvic floor function & the pubo-coccygeus muscle
2-  to appraise the pelvic floor muscle relaxation and act on the information
3-     to release chronic pelvic tension
4-     to correct a reverse perineal command
5-     to integrate the correct perineal blocking before stress

Biofeedback in urological disorders

Objectives for BFB in urological disorders:
1-     to acquire an increased awareness of patients voiding pattern
2-     to train muscles involved in the continence mechanism

Definition and goals of biofeedback

    To detect, show & measure internal physiological events
    To teach, promote & develop conscious control over body processes

So goals are:
    physiological self regulation
    development of new habits or responses
    an improvement of patient’s life

Applied biofeedback

The previous learning process for these goals is:
1-   To develop levator ani contraction before any rise in abdominal pressure using two biofeedback channels e.g. a vaginal and an abdominal at the same time, with EMG recruitment, or with pressure biofeedback.
2-    To perform EMG exercises in a standing position to control reflex PFM contractions and voluntary PFM contractions.
3-     To adapt the programme to meet the women’s requirements

Biofeedback must be relevant in order to enhance learning and to focus attention on agonist (pelvic floor muscles) and antagonist muscles (abdominal muscles). Therapy concentrated on inhibition of the antagonist while attempting to increase the response of the agonist (pubo-coccygeous and puborectal), whilst contracting the external anus sphincter by observing the proper channel of the EMG tracing.
We know that once movement occurs, the EMG force relationship depends upon the speed of contraction and the length of the muscles involved.

Since the objective for performing the contraction is to contract the striated muscles properly, the proprioceptive signals generated by the muscles surrounding the pelvic floor can easily be misinterpreted as originating from the pelvic floor itself rather from the antagonist muscles represented by strong abdominal muscles. This incorrect manoeuvre perpetuates the substitution pattern and delays the development of an increased awareness of the isolated pelvic floor muscles. Another problem occurs when abdominal substitution pattern develops and is used when attempting to "hold back". This abdominal contraction with the incorrect manoeuvre of pushing down, described as a "reverse perineal command» causes a rise in intra-abdominal pressure. In that case, with such recruitment, this contraction would only maximize a rise of intra-abdominal pressure, which would increase EMG abdominal signals.

Abdominal muscle contractions are measured by widely spaced surface electromyographic electrodes. For this reason, we do not recommend home exercises during these early weeks of treatment, knowing that patients could reinforce the inappropriate response by antagonist muscles and extinguish the appropriate response. As soon as the patient is able to contract the pelvic floor muscle, we ask her to position her hand on her abdomen to feel the faulty abdominal contraction. This is a complementary and a very simple exercise similar to Kegel's exercises for women.

 With biofeedback therapy, information provides the patients with a method:
- To acquire voluntary control over skeletal muscle such as anal sphincter and / or levator ani muscles;
-  To enable patients to develop a heightened sensory awareness of the pelvic function;
-  To increase active muscle contractions;
-  To decrease general muscle antagonist spasms when pain is associated;

The benefits of biofeedback therapy are rapidly obtained by most patients. The procedures involve minimal medical risk.

Conditioning techniques bladder

    to give a clear description of normal voiding function
    to restore the individual confidence in voluntary ability to hold urine
    to re-establish a more normal pattern

Algorithm for physiotherapy management

Regarding the PFM we quote the pubo-coccygeus contraction in a range from zero to five, e.g.: score = 0 = weakest / score = 5 = strongest

•    score 0,1,2 =    
Genuine Stress Incontinence = clinic therapy (FES), BFB, PFM
Urge Incontinence = BFB, home treatment (FES)
Mixed Incontinence = BFB, home treatment (FES) & PF Muscle Exercises

•    score 3,4,5 =    BFB control blocking, PF Muscle Exercises & cones

References

•    A.Bourcier, G.Amarenco, M.Bonierbale, JP Dentz, J.Juras, A.Mamberti-Dias, M.Perrigot, F. Roman, JY Touchais, J.Weber. Le plancher pelvien. Explorations fonctionnelles et réadaptation. Vigot 1989
•    Bisschop G. [de], Bisschop E. [de], Commandré F. Electrophysiothérapie. Paris : Masson, 1999.
•    Bisschop G. [de], Bisschop E. [de], Gouget JL. Le complexe périnéo-vésico-sphinctérien. CR 2ème Journée Amiénoise de Rééducation Pelvienne 1996:19 pp.
•    Bisschop G. [de], Bisschop E. [de]. Le nerf normal et pathologique : répercussions électrophysiologiques.In : Beco J, Mouchel J, Nélissen G. La périnéologie…Comprendre un équilibre et le préserver. B-Verviers : Odyssée 1372, 1988:1-19.
•    Erlandson BE, Fall M, Sundin T. Intravaginal electrical stimulation. Clinical experiments of urethral closure. Scand J Urol Nephrol 1977;44:31.
•    Fall M, Carlsson CA, Erlandson BE. Electrostimulation of patients with dysfunction of the lower urinary tract. Artif Organs 1981;5:606.
•    Fall M. Does electrostimulation cure urinary incontinence. J Urol 1984;131:664-7.
•    Pigne A, Kunst D, Cotelle O, Oudin G, Banat J. Electrostimulation fonctionnelle et incontinence urinaire d post-partum 1986. SIFUD. Lisbonne.
•    Prat-Pradal D. et al. Intérêt des explorations électromyographiques dans la rééducation  périnéale. Actualités en Rééd Fonct et Réadapt 1989,14.
•    Emma Dolfo, Paolo di Benedetto. Chinesiterapie pelvi-perineale. ART- 1993
•    Carlo Cisari, Gabriele Severini. Fisioterapia clinica pratica. Fisioline. 1999 – Edi.Ermes srl
•    P.diBenedetto. Riabilitazione uroginecologica. Edi. Minerva Medica  - 1995
•    B.de Gasquet. Abdominaux : arrêtez le massacre. Edi. Santé-Robert Jauze - 2003

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