IN THE NAME OF GOD

1. IN THE NAME OF GOD Afsaneh Nikjooy 90/3/11

2. Biofeedback & Electrotherapy for Pelvic Floor Dysfunction AfsanehNikjooyPhDcandidate ,PTTehrunUniversity of MedicalScience

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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 stimulation Afsaneh Nikjooy 90/3/11

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. ES shouldn’t routinely be used in combination with pelvic floor muscle training Afsaneh Nikjooy 90/3/11

19. Thanks for your attention Afsaneh Nikjooy 90/3/11