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Electrical stimulation for the pelvic floor

Electrical stimulation is commonly used and recommended for many conditions including:

  • Improving the  strength of your pelvic floor muscles if they are very weak or deconditioned.
  • Helping to locate, identify and isolate the pelvic floor muscles to help you learn how to do a pelvic floor muscle contraction correctly. Some people have good tone in their muscles but are not 'connected' well enough to be able to voluntarily contract them. E-stim can be helpful to re-educate the sensorimotor pathways to help you learn how to contract correctly.
  • Helping to relax the pelvic floor muscles  
  • In the form of TENS it can be used very successfully for reducing bladder and bowel urgency which often results in loss of control.
  • Persistent pelvic pain can respond well to including some TENS in treatment. It can replace drugs in many cases and is non- invasive, cheap and risk free with no side effects.
  • Labour pain can be helped with the use of a special TENS unit with a remote control for the user to take charge, allowing her to change the modulating input sensation when a contraction starts. This same machine can be extremely helpful with severe pelvic pain often experienced by women with endometriosis.

Electrical Stimulation comes in many forms and has several names. They are all neuromodulation of some kind - in other words ways of modulating the nervous system via the spinal cord or the peripheral nerves to modulate or alter the signals to the brain.
This can help reduce the experience of pain, to help muscles contract or to calm the neural input to organs to reduce overactivity ( eg the bladder).

SOME FACTS : 

  • Nerves DO NOT send pain messages to the brain
  • TENS machines DO NOT block the nerve pain messages to the brain, stopping the pain
  • Pain is an output of the brain
  • You will still read on many websites that nerves send pain messages and these can be blocked . Messages from nerves are processed by the brain and the level of danger or threat is assessed and the response is appropriate to the situation. We can interrupt or modulate the messages going to the brain but we are not blocking them or gating them in the way we used to understand the mechanism. Pain science has come a long way in recent years and it is taking time for some to catch up on the latest research.
    To learn more, visit the website Body In Mind

It can be confusing to know which does what and what all the terms mean! The main differences are in the parameters used, which will affect the type of nerves and muscle fibres stimulated, and the mode of delivery - across the skin ( transcutaneous) or through the skin ( percutaneous) 

Electrical stimulation may be able to help a range of pelvic floor dysfunctions :

  • Stress urinary incontinence
  • Urge urinary incontinence
  • Bladder urgency
  • Faecal incontinence
  • Faecal urgency
  • Pelvic pain 
  • Painful sex
  • Period pain
  • Pelvic pain of any origin 

How does electrical stimulation work?
 

When electrical stimulation is applied to the body, it creates a flow or current of electrically charged particles, which in turn creates physiological changes in the tissue through which the charge flows. Therefore if you apply electrical stimulation to the pelvic floor muscles, you can create changes in these muscles.
Pelvic floor electrical stimulation is usually a pulsed “bi-directional and biphasic” current. This means that charged particles move in one direction, drop to zero, and then change direction. This type of current reduces the chance of skin irritation.

Research suggests that electrical stimulation can:

  • Increase the proportion of fast twitch fibers of the pelvic floor muscles
  • Increase the number and strength of slow twitch fibers of the pelvic floor muscles making it easier to achieve stronger pelvic muscle contractions.
  • Help reduce the bladderl over-activity and bladder contractions that cause urge incontinence,  frequency and urgency problems
  • Help reduce faecal incontinence and urgency 

Some of the names and terms used when describing electrical stimulation :

  • ES : Electrical Stimulation
  • NMES : Neuro Muscular Electrical Stimulation
  • E-Stim: Electrical Stimulation
  • FES : Functional Electrical Stimulation : produces a functional action from muscles eg extends the wrist 
  • TENS : Transcutaneous Electrical Nerve Stimulation: stimulates sensory (feeling) nerves via skin (cutaneous) electrodes : most often used for pain
  • SNS / SNM : Sacral Nerve Stimulation / Sacral NeuroModulation: two names for the same thing : implanted stimulators that affect the sacral nerve roots
  • SNS: Spinal Nerve Stimulation : implanted stimulator that affects the spinal nerves directly
  • PENS : Percutaneous Electrical Nerve Stimulation : stimulates nerves via needles inserted near the nerve : often used in theatre by pain specialists for spinal nerve stimulation with the patient sedated 

 

Different frequencies and other parameters of stimulation are used for different goals. For example we would use completely different settings for calming an urgent bladder down to those we would use to strengthen your pelvic floor muscles.


    Terms associated with electrical stimulation of the pelvic floor and what they mean.

    Electrical stimulation is described in terms of parameters or settings:

    Amplitude is the measure of intensity of the electrical current, and is usually expressed as mA. Electrical stimulation devices allow you to control the level of intensity, which should be at a comfortable level. When stimulating pelvic floor muscles to contract, the current should be strong enough to cause a contraction- this may take a few sessions to build up to as you get used to the sensation.

    Frequency is the number of pulses that are generated per second and is expressed as Hz and pronounced “hertz”. The best frequency for electrical stimulation varies according to the nerve being targeted and this depends on the condition being treated. Generally, stress urinary incontinence is treated with frequencies between 20-50HZ and urge incontinence with frequencies between 10-15HZ.
    Higher frequencies build strength by stimulating the fast twitch muscle fibres , and help to bulk up muscle increasing the ability of the pelvic floor muscles to help close the urethra and prevent the leakage associated with stress incontinence.
    Low frequencies have a calming effect on the bladder muscle and therefore reduce bladder contractions. However, patients with urge incontinence can often benefit from high frequency treatment as well as low frequency, as increased muscle strength also helps with controlling the urge to urinate.

    Pulse Width : is how long each of the pulses last. The higher the width, the deeper the pulse will penetrate so this affects the type of nerve fibre stimulated.

    Ramping is the speed at which the electrical current reaches the muscle . The more slowly the current rises to its maximum intensity, the more comfortable the stimulation will feel. With a faster ramp, it is more likely that the user will feel some discomfort.

    On/Off  or Work/Rest time. On time is the amount of time that the electrical stimulation is active (work), Off time is the amount of time when there is no electrical current (Rest). Off time is important to allow the muscle to recover when using it for stimulating muscle contractions. When using TENS, the current is continuous so there is no work/rest setting.


    Who should NOT use electrical stimulation?

    Some people cannot use electrical stimulation including those with:

    • IUD, pessary (when in situ), any metal implants in the area (eg Filshie clips used for tubal ligation). Check with your treating health professional
    • check with your doctor hip joint replacement if using for pevic floor.
    • Cardiac pacemaker or cardiac arrhythmia
    • Pregnancy or planning a pregnancy
    • Broken/irritated skin in the rectal, vaginal or perineal area
    • Rectal bleeding or haemorrhoids
    • Bladder or vaginal infections
    • Seizure and dementia conditions

     


    What does this mean for choosing an electrical stimulation device?

    Our devices are easy to use and feature pre-set programs for various conditions as well as custom programs that can be set to individualised parameters, by your health professional, specifically for your treatment. The preset programs are named for conditions by the manufacturers which can be a little confusing. For example your aim may be to strengthen your pelvic floor but there are no programs called Strengthen. They will usually be named Stress Incontinence - because this is the condition that most commonly requires strengthening of the pelvic floor muscles. Be aware that more programs does not mean a superior machine. The value in your machine comes with its ability to have the parameters manipulated to suit your condition.

    *The strength or intensity of the stimulation (mA) is always under your control.
     

    Stress Urinary Incontinence: normally requires strengthening of the pelvic floor muscles and will use programs in the range of 20 - 40 Hz with various work/rest times. When starting out, choose a program with a longer rest than work. As you progress you can shorten the rest time and increase the work time which will help build endurance in your pelvic floor muscles.
    Even if you don't leak, but are aiming to strengthen the pelvic floor, use these programs. 
    If you find the preset program in the 30-40Hz range too strong or uncomfortable, you can try the preset 20Hz program and once used to that you can change the the higher frequency program of  30-40Hz.
    There are programs for this in the Pericalm, Pelvitone and Continence

    Urgency / Urge Urinary Incontinence / Faecal urgency or Incontinence: uses lower frequencies or Hz which are aimed at calming the nerves to the bladder and rectum, making them less irritated. These programs will normally be around 10 Hz.

    Pelvic Pain : pain settings are normally at the lower end around 2-5Hz or the higher end 120-150Hz. The pelvic floor stimulation machines tend to use the lower settings in the preset programs ( Pericalm, Pelvitone and Continence) whereas the Obstetric machines use the higher end Hz. The TENS machine uses a range of settings, allowing you to choose which works best for you.


    So which machine do I choose?

    It can be confusing trying to work out which is the best machine for you.
    The main consideration when choosing is what do I need my machine to do? 

    This summary may help:
    Neurotrac TENS :

    • for pain - any type
    • for urinary or faecal urgency when you are going to use it to calm the bladder and bowel

    Neurotrac Obstetric TENS

    • for pain relief during labour
    • for persistent pelvic pain especially when associated with Endometriosis. The cramping pain with Endometriosis is often likened to labour pain. Using an Obstetric TENS with its boost remote can be very helpful during spikes in pain.

    Pericalm 

    • has a range of programs for strengthening , calming and pain but will not allow custom programming with continuous ( as in TENS) - it will only allow work/rest stimulation custom programs. 

    Neurotrac Continence

    • as for the Pericalm but this is our most cost-effective machine for home use.

    Neurotrac Pelvitone   

    • Does the same as the Pericalm and Continence but allows for a continuous program in the custom settings, however clinicians be aware that this only goes p to 100Hz so if you intend to use higher frequencies you will need a TENS machine. It also allows for a multi-phase program to be set so can be a useful machine for clinicians. 

    Electrodes

    Firstly - all of the electrodes that we sell are compatible with all of the machines we sell. This includes stimulation machines, TENS machines and EMG machines
    Secondly - Leads are supplied with your machine. These leads plug into the machine and the electrodes plug into the leads. Your electrode does NOT plug directly into your machine.
    Thirdly - electrodes and leads are delicate and the wires within are easily damaged. Do not pull your electrode out ,or off, by the leads. Use the flange on the end of the electrode, or peel the adhesive ones careful off via the sticky part.

    We are often asked which electrode should I buy?
    This is very individual and depends on a number of factors. 

    1. Choose your internal electrode based on size and shape required.
        Vaginal electrodes need to fit the hiatus or width of the vagina to get good contact. You can learn how to test vaginal size here
        Most women who have had babies will need a wider electrode.

    2. Do you need an external (adhesive electrode) ? Size will depend on where you will be using it. The surface area of the electrode - the part thatattaches to the skin - determines the concentration of the current felt, so the smaller the electrode, the more concentrated the current and should be used for smaller areas. Smaller area = smaller electrode. Larger area = larger electrode.

    3. Budget should be the last consideration with an electrode. You need it to do the job required so choose the most effective one for you. Often people will spend more on a stimulation machine because it has more programs so sounds better, and then less on their electrode. In fact you only need a stimulation machine that has the correct parameters for you - often the other 10 programs are not needed for your condition. 


    Troubleshooting with your stimulation machine

    Sometimes things go wrong and your machine may appear to be malfunctioning. 
    ALL of our machines have a built in safety function that will not allow the intensity to go past 5-6mA if the circuit is incomplete.
    The majority of the time this is due to a broken or damaged wire in either the electrode or the lead and this is almost always due to incorrect handling.
    The leads and electrodes are delicate and the internal wires will break if roughly handled. This includes being removed via the leads rather than the flange on the end of internal electrodes, or by the leads of the adhesive electrodes ( they need to be peeled off via the sticky electrode)

    Stimulation machines don't like to be dropped either - this can damage the internal circuitry. 

    If your machine won't register past 5-6mA , your machine is working and you need to determine where the loss of contact is.
    This can be:

    1. Lack of contact with the skin or tissue being stimulated ( vaginal walls or rectum in the case of pelvic floor conditions)
    2. Broken wire in the elecrode
    3. Broken wire in the lead

    You can download our troubleshooting instructions to see how to fix any of these problems.


    The material presented in this information sheet is intended as an information source only. The information is provided solely on the basis that readers will be responsible for making their own assessment of the matters presented herein and are advised to verify all relevant representations, statements and information. The information should not be considered complete and should not be used in place of the advice of a health care provider. Pelvic Floor Exercise does not accept liability to any person for the information or advice provided in this sheet, or for loss or damages incurred as a result of reliance upon the material contained herein.

    ©Pelvic Floor Exercise all rights reserved

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