Transcript nikjooy

IN THE NAME OF GOD
Afsaneh Nikjooy
90/3/11
1
Biofeedback & Electrotherapy
for Pelvic Floor Dysfunction
Afsaneh Nikjooy
PhD candidate ,PT
Tehrun University of Medical Science
The ICS definition of the
Biofeedback
• The technique by which information about
a normally unconscious physiological
process is presented to patient or therapist
or both as a visual,auditory or tactile signal
• Biofeedback can promote awareness of
the physiological action of PFM and
patient motivation for example by
manometry or electromyography(EMG)
Afsaneh Nikjooy
90/3/11
3
Pelvic floor retraining
with EMG biofeedback
– to help identify pelvic floor musculature
– to perceive difference between
contraction, relaxation, and straining
– to voluntary relax pelvic floor during
voiding & defecation
Afsaneh Nikjooy
90/3/11
4
BF therapy is considered the first line of
treatment for stress ,urge and mixed UI ,fecal
incontinence ,paradoxical puborecctalis
contraction(functional constipation),pelvic pain
,and other forms of PF dysfunction
• The BF may be via an anal pressure probe to
display sphincter pressure( vaginal) or EMG
electrodes to display sphincter electrical activity
either intra-anally / intra -vaginally or, surface
electrode, externally on the anal sphincter.
Afsaneh Nikjooy
90/3/11
5
CONT’D
• Mean success rate for BF range from
72.3%,for fecal IN 68,5%,for constipation
attributable to paradoxical PPC syndrome
and 41.2% for idiopathic rectal pain
Afsaneh Nikjooy
90/3/11
6
• It is difficult to offer a specific standard BF
protocol that is beneficial for all patients
therefor an individualized program must be
planed
• The ultimate clinical goal of BF is to
influence a body response independent of
this stimulus.
• BF is a simple ,cost-effective and
morbidity free technique for functional
disorders of PF(Jose Marcio et.al 2003)
Afsaneh Nikjooy
90/3/11
7
• Training for dyssynergia ,incontinence or
pain begins with isolated pelvic muscle
contractions
• Observation of other accessory muscle
use such as the gluteal or thighs
(adductors) is discussed with the patient.
Afsaneh Nikjooy
90/3/11
8
CONT’D
 Excessive pelvic muscle activity with an elevated
resting tone more than 2 microvolt may be
associated with dyssynergia ,voiding and
defecation dysfunction and pelvic pain.
 If there is a problem with reduced sensation to
rectal filling ,sensivity training(discrimination
training) with rectal balloon expulsion is used to
re-educate the contraction of the EAS in
response to rectal distension. the aim is rectal
sensory awareness and anal sensation
Afsaneh Nikjooy
90/3/11
stimulation
CONT’D
•
•
In urinary and faecal incontinence ,the aim is
reducing the frequency of incontinence
episodes ,improving rectal sensibility and
changing the quality of stool.
During the initial session ,the objectives of BF
therapy and the basic anatomy and physiology
of the pelvic floor (bowel,bladder and PFM
function ) are fully explained to patient .
Afsaneh Nikjooy
90/3/11
10
CONT’D
• It must be monitored PFMs with controlling
changes in intra-abdominal pressure
 Inta-vaginal ,intra-rectal or perianal place –ment
of surface electrodes may be used to monitor
the PFMs
 To obtain an evaluation ,patients are instructed
to relax and then perform an isolated pelvic
muscle contraction over 10 second period
followed by performing a valsalva
manoeuvre,this sequence is repeated 2-4 times
for accuracy.
Afsaneh Nikjooy
90/3/11
11
CONT’D
 The abdominal muscle activity should remain
low and stable ,indicating the patient‘s ability to
isolated PMT contraction from abdominal
contraction
 Valsalva manoeuvre PFM activity should
decreased below the resting baseline ,while the
abdominal sEMG activity increases with
elevated intra-abdominal pressure
 These objective measurements are reviewed
with the patient and provides the clinician to
guide training and recommended at home
practice
Afsaneh Nikjooy
90/3/11
12
BF improved the defecations rate by;
(in paradoxical puborectalis contraction)
•
•
•
•
•
Inflounced positively the defecation reflex
Improving rectal sensation
Changing the anorectal angles
Diminishing the EMG voltage of EAS
Although the act of defecation is a complex
phenomenon dependent up on many factor in
anorectal and high centers ,it can be influenced
by a self regulatory mechanism that depends on
the patient’s will and effort
Afsaneh Nikjooy
90/3/11
13
BF inflounced positively the defecation reflex,
leading to an improved quality of higher
control bowel function;
• Re enforcing its afferent limb by improved
anorectal sensation
• Recruiting the higher centers in the
conscious control of the act
• Through efferent limb provided increased
relaxation of PF and sphincter
musculature
Afsaneh Nikjooy
90/3/11
14
Adding home training with a feedback
device
• Perinometers
• Weighted vaginal cones
• The most convenient and the cheapest
form of BF is using patient’s fingers with in
her vagina (at initial anorectal assessment
digital proprioceptive BF may be given to
increase patient awareness).
Afsaneh Nikjooy
90/3/11
15
Electrical stimulation (ES)
IF,APC,Faradic
• ES has been used as a method of re-education
of muscle by rasing cortical awareness
,normalising reflex activity and having a direct
affect on the muscle stimulated
 If a patient is assessed to have a low voluntary
anal or vaginal squeeze on examination,and
EXS dosen’t seem to be leading to be to any
improvement ,ES by a home treatment unit for
daily use or attendance for clinic-based therapy
can be used.
Afsaneh Nikjooy
90/3/11
16
CONT’D
• ES involves the application of electrical
current ,usually via vaginal/anal or surface
electrodes ,to stimulate the PFM via their
nerve supply (pudendal nerve)
• An anal /vaginal electrode should be used
to ensure that maximal stimulation can
take place.But care must be taken about
the anal ,as the anal mucosa is often more
sensitive that vaginal mucosa.
Afsaneh Nikjooy
90/3/11
17
ES shouldn’t routinely be used
in combination with pelvic floor
muscle training
Afsaneh Nikjooy
90/3/11
18
Thanks for your attention
Afsaneh Nikjooy
90/3/11
19