电刺激在尿失禁治疗中之技巧及运用课件

電刺激在尿失禁治療中之技巧及電刺激在尿失禁治療中之技巧及 運用運用 陳怡靜陳怡靜 中山醫學大學中山醫學大學 物理治療學系物理治療學系 講師講師 中山醫學大學附設醫院中山醫學大學附設醫院 物理治療師物理治療師 Types of IncontinenceTypes of Incontinence Stress incontinence Stress incontinence Urge incontinence Urge incontinence Mixed incontinence Mixed incontinence Reflex incontinence Reflex incontinence Overflow incontinenceOverflow incontinence Treatment for Urinary IncontinenceTreatment for Urinary Incontinence Federal Agency for Health Care Policy and Research Federal Agency for Health Care Policy and Research (AHCPR), 1996(AHCPR), 1996 Behavioral treatmentBehavioral treatment Pharmacologic treatmentPharmacologic treatment Surgical treatmentSurgical treatment Behavioral TherapyBehavioral Therapy Bladder retrainingBladder retraining Pelvic muscle rehabilitation Pelvic muscle rehabilitation PMEsPMEs, , PMEsPMEs and bladder inhibition augmented and bladder inhibition augmented by biofeedback therapy, by biofeedback therapy, PMEsPMEs augmented with vaginal weight training, augmented with vaginal weight training, and pelvic floor electrical stimulationand pelvic floor electrical stimulation Different frequencies of stimulation are Different frequencies of stimulation are advocated for the activation of these advocated for the activation of these different nerve fibresdifferent nerve fibres the the pudendal efferents (alpha-motor axons)pudendal efferents (alpha-motor axons) produces a contraction of the levator aniproduces a contraction of the levator ani the the pudendal afferent (medium-size pudendal afferent (medium-size myelinated)myelinated) will active the inhibit premature, will active the inhibit premature, unwanted bladder contractionsunwanted bladder contractions Physiological EffectsPhysiological Effects Improvement of Improvement of reinnervationreinnervation of partly of partly denervateddenervated PFMsPFMs by encouraging axonal by encouraging axonal sprouting.sprouting. Muscle strength is increased in a similar Muscle strength is increased in a similar manner to voluntary exercise.manner to voluntary exercise. Electrically elicited contractions can target and Electrically elicited contractions can target and train type 2 (fast-twitch) fibers effectively. train type 2 (fast-twitch) fibers effectively. Mechanism of Action:Mechanism of Action: Electrical stimulation activates a reflex with the Electrical stimulation activates a reflex with the pudendalpudendal nerve afferent limb and with the following central nerve afferent limb and with the following central actions:actions: Activation of Activation of sympathetic inhibitorysympathetic inhibitory fibers ( fibers ( hypogastrichypogastric inhibitory fibers) to pelvic ganglia inhibitory fibers) to pelvic ganglia and the and the detrusordetrusor Central inhibitionCentral inhibition of the pelvic motor outflow to of the pelvic motor outflow to the bladderthe bladder Electrical StimulationElectrical Stimulation Increase Increase awareness awareness of the PFMof the PFM TeachTeach effective PFM exercise effective PFM exercise IncreaseIncrease periperi-urethral pressure-urethral pressure InhibitInhibit detrusordetrusor contraction contraction Electrical ParametersElectrical Parameters Frequency:Frequency: -10 Hz or less in the treatment of bladder -10 Hz or less in the treatment of bladder instability.instability. -10-50 Hz in treatment of weakened pelvic -10-50 Hz in treatment of weakened pelvic floor muscle.floor muscle. Electrical ParametersElectrical Parameters Intensity: Intensity: maximal tolerated levelmaximal tolerated level Pulse width (pulse duration): Pulse width (pulse duration): 0.2- 0.5ms0.2- 0.5ms Electrical ParametersElectrical Parameters Electrical ParametersElectrical Parameters On/off ratio (duty cycle): On/off ratio (duty cycle): 1:1 or 1:21:1 or 1:2 Electrical stimulation delivery systemElectrical stimulation delivery system NonimplantedNonimplanted delivery system: delivery system: vaginal, anal, surface electrode vaginal, anal, surface electrode Electrical stimulation delivery systemElectrical stimulation delivery system TranscutaneousTranscutaneous Electrical Stimulation Electrical Stimulation PercutaneousPercutaneous TibialTibial Nerve Stimulation Nerve Stimulation TransvaginalTransvaginal electrical stimulation for female electrical stimulation for female urinary incontinenceurinary incontinence A prospective, double-blind, randomized A prospective, double-blind, randomized clinical trialclinical trial 49% of women with 49% of women with detrusordetrusor instability who instability who used an active electrical device were cured ( used an active electrical device were cured ( stable on provocative stable on provocative cyctometrycyctometry). ). no statistically significant change in the no statistically significant change in the percentage with percentage with detrusordetrusor instability in the instability in the sham device group (control group).sham device group (control group). Brubaker L et al: Am J Brubaker L et al: Am J ObstetObstet GynecolGynecol 1997; 177(3): 536-540 1997; 177(3): 536-540 IntravaginalIntravaginal stimulation randomized trial stimulation randomized trial Electrical stimulation is Electrical stimulation is safe and at least as safe and at least as effectiveeffective as as anticholinergicanticholinergic therapy in the therapy in the treatment of urge urinary incontinence.treatment of urge urinary incontinence. Smith JJ: J Smith JJ: J UrolUrol 1996; 155:127-130 1996; 155:127-130 no significant differencesno significant differences between daily and between daily and every-other-day users.every-other-day users. Siegel SW et al: Urology 1997; 50:934-940.Siegel SW et al: Urology 1997; 50:934-940. Pelvic floor electrical stimulation for the treatment Pelvic floor electrical stimulation for the treatment of urge and mixed urinary incontinence on womenof urge and mixed urinary incontinence on women The greatest The greatest improvement in the improvement in the first 6 weeksfirst 6 weeks Twenty weeksTwenty weeks of of pelvic floor electrical pelvic floor electrical stimulation therapy stimulation therapy is effectiveis effective Adverse EffectsAdverse Effects TransrectalTransrectal stimulation stimulation Abdominal crampsAbdominal cramps DiarrhoeaDiarrhoea Anal painAnal pain Anal bleedingAnal bleeding IntravaginalIntravaginal stimulation stimulation Vaginal irritation Vaginal irritation Pain Pain bleedingbleeding ContraindicationsContraindications Implanted pacemakerImplanted pacemaker PregnancyPregnancy Malignant Malignant tumourtumour Atrophic Atrophic vaginitisvaginitis, vaginal infection, vaginal infection Recent or recurrent Recent or recurrent haemorrhagehaemorrhage/ / haematomahaematoma Patients-Oriented ApproachPatients-Oriented Approach OveractiveOveractive bladder bladder Functional Functional limitationlimitation Weak pelvic Weak pelvic floor musclefloor muscle Payne C.K. Urology, 2000; 55 (Payne C.K. Urology, 2000; 55 (SupplSuppl 5): 3-6 5): 3-6 patientspatientsclinicclinic Urodynamic Urodynamic evaluationevaluation SUISUI DIDI MIMI PFMEPFME functional functional abdominal/ PFM use abdominal/ PFM use (PBBS)(PBBS) PFMEPFME bladder re-training bladder re-training ES ES urge control technique urge control technique GSI +DIGSI +DI PhysiotherapyPhysiotherapy Pelvic Floor Re-educationPelvic Floor Re-education Pelvic Floor AssessmentPelvic Flo