© Borgis - New Medicine 1/2008, s. 3-7
*Krystyna Garstka-Namysł1, Juliusz Huber 2, Alicja Witkowska2, Magdalena Pisarska3, Kamila Witczak3, Łukasz Sroka3, Stefan Sajdak3, Grzegorz H. Bręborowicz4
INDIVIDUALLY PLANNED FUNCTIONAL ETS AND EMG BIOFEEDBACK AND SUPRASPINAL FES STIMULATION OF PELVIC FLOOR MUSCLES IN WOMEN AFTER GYNAECOLOGICAL OPERATIONS WITH SYMPTOMS OF URINARY INCONTINENCY
1Section of Recreational Sports in the Chair of Pedagogy of Leisure and Recreation of the University School of Physical Education in Poznań Head of Section: Dr Krystyna Garstka-Namysł 2Department of Pathophysiology of Motor Organs of the University of Medical Sciences in Poznań 3Chair and Clinic of Perinatology and Gynaecology of the University of Medical Science in Poznań 4Department of Hygiene of the University School of Physical Education in Poznań
Background: Women with symptoms of urinary incontinence and after gynaecological operations experience pelvic floor muscle and nerve action disorders which significantly affect their functional state. On the basis of the results of global electromyography, parameters for supraspinal stimulation (FES) and transvaginal electrical muscle stimulation (EMS) can be individually specified and the effects of therapy objectively assessed.
Material and methods: In 25 randomly selected (out of 236) women after gynaecological operations (on average 9 months after operations) with symptoms of micturition disorders the following examinations were carried out: gynaecological, urodynamic, ultrasonographic and psychological. In patients without contraindications for electrotherapy, global electromyography using an intravaginal electrode was carried out as well as examination of motor evoked potentials (MEP) induced by a magnetic field. Parameters for EMS and FES were selected individually, on the basis of the diagnostics results of nervous and muscular disorders. Comparative EMG and MEP were carried out after patients had undergone the therapy for two months at home.
Results: on the basis of diagnostic tests in 85% of patients a neurogenic cause of the complaints was found in the form of axonopathy of motor fibres rather than weakening of impulsation at the level of neurons of the motor centre. Muscle resting tone was on average 2.52 ?V before the therapy and 1.87 ?V after therapy. Action potential in the phase of contraction was 11.41 ?V before and 16.92 ?V after therapy.
Conclusions: EMG tests have shown a beneficial, statistically significant increase in the amplitude of muscle tone measured in exercise conditions. A two-monthly therapeutic cycle of electrostimulation resulted in an improvement of the functional state of motor units (stability) in the conditions of maximum contraction and post-exercise relaxation. Our study demonstrates that therapy of muscle activity disorders using the EMS and FES methods preceded by global electromyography and visualisation of contraction using EMG biofeedback has expected therapeutic effects.
In the literature statistical studies show definitely that a gynaecological operation such as hysterectomy causes a basic change in the life of a woman, in particular if it is related to post-operative micturition disorders. In the study of Ralph and Lichtenegger (1988)  it was found that compliance of the bladder deteriorates in 69% and incontinence occurs in 31% of patients after radical hysterectomy. In the long-term studies of Sekido, Kawai and Akaza (1997) [2, 3] it was demonstrated that even ten years after hysterectomy, disorders in the urinary passage can be observed, as well as such dysfunctions as constipation, retention of urine, and detrusor hyporeflexia. Other neurological studies of Chang et al. (2003)  showed that damage of somatic and autonomic nerves cause micturition disorders in patients after radical hysterectomy. Taking into consideration the fact that hysterectomy is the most frequently performed gynaecological operation in Poland and in the world , it is important to develop effective methods of prevention and treatment of micturition disorders caused by hysterectomy, adjusted individually for a patient´s indications. Physiotherapy is considered by many authors an irreplaceable method in the treatment of pelvic floor muscle disorders, including urinary incontinence [6, 7, 8]. Physiotherapy methods include EMG biofeedback exercises and electrotherapy involving electric stimulation of pelvic floor muscles and supraspinal functional stimulation [9, 10, 11].
The use of global electromyography for diagnosis and treatment of muscle activity disorders allows objectivisation of tests [12, 13] and the use of EMG biofeedback methods significantly increases the effects of therapy [14, 15, 16, 17, 18]. Due to various health components leading to the same symptoms in various patients, we decided to establish individually parameters of the NMES and FES electrotherapy and EMG biofeedback exercises, on the basis of the diagnostic test results and tests of Work/Rest muscle activity carried out under the control of non-invasive global electromyography (transdermal).
Material and methods
The study covered 25 women randomly selected from a group of 236 patients after gynaecological operations, on average M=8.6 months after their operations, with symptoms of urinary incontinence. All women from the experimental group were qualified for the study (gynaecological, ultrasonographic, urodynamic, psychological, neurophysical examinations) and their socio-demographic characteristics were established.
UD diagnostics on the basis of natural uroflometry with the measurement of residual urine, water cystometry and urethral profilometry was carried out, using the DUET Logic/MultiP (Medtronic) device, according to medical indications. Before the UD test, general urine and urine culture analysis was carried out. All patients with urinary tract infection symptoms were excluded. In women with a history of recurrent urinary tract infections, anti-inflammatory prophylaxis was started before the urodynamic examination.
For the EMG test an integrated Key Point Portable system (Medtronic) and the system of global EMG measurement – NeuroTrac(r)ETS (Verity Medical Ltd.) were used. The first EMG measurement was carried out after the operation, directly before beginning therapy (2 months at the earliest, 18 months at the latest, 8.6 months on average) in order to establish neurogenic components of incontinence symptoms and the degree of muscle activity disorder intensity. The second measurement was carried out directly after the therapy. EMG recordings and later electrostimulation were performed using an intra-vaginal electrode Veriprobe (Verity Medical Ltd.) inserted by the patient herself. Patients were carefully prepared and instructed for this.
The first stage of the EMG test using the 2-channel NeuroTrac(r)ETS device involved assessing the pelvic floor muscle resting tone in lying and standing position followed by the standardised muscle activity test Work/Rest Assessment, including five 5-second contraction cycles (Work) followed by five relaxation cycles (Rest). This test allowed us to establish the average value (expressed in microvolts) of muscle activity in the contraction and relaxation stage (mean and standard deviation for each of the stages separately), which describes the stability of muscle tone in the stage of contraction and relaxation, and the average time (expressed in seconds) of reaction to order of contraction and relaxation. After a three-minute rest, each patient carried out exercise tests as a sequence of ordered activities: retraction of the anus, pressure test, laugh test, cough test in the lying and standing position. There was a 30- second rest after each activity. The results of the resting and exercise tests made it possible to establish muscle efficiency, the range of conscious control over their activity and to adjust individually parameters of FES and NMES stimulation.
The second stage of the EMG test performed using the same intra-vaginal electrode on the Key Point device involved carrying out the same sequences of activities as in the first stage and recording potentials from the muscles characteristic for a given activity.
In the third stage motor evoked potentials (MEP) induced by a magnetic field were recorded within motor units of sacral neurosegments of the spinal cord.
A psychological test was carried out using questionnaires on the sense of quality of life according to S. Kowalik and questionnaires in the authors´ own perspective which measured five functional states of life situation of women, including physical, material, social and mental state as well as state of life activity and fitness. Getting to know these spheres of life and ways of their evaluation makes it possible to establish the psychological consequences (changes in evaluation) of a gynaecological operation and of a specially selected therapy.
On the basis of the collected diagnostic data, parameters of neuro-muscular electrical stimulation (NMES) were set as well as parameters of functional supraspinal stimulation (FES). Significant differences in results of exercise and muscle resting tone and disorders of conduction of motor nerves found in the MEP test required the use of varied parameters of simulation, appropriate for the test results. Patients were equipped with a specialist pelvic floor muscle and nerve stimulator, intra-vaginal electrode (Veriprobe) and a set of self-adhesive electrodes 50x100 mm (Verity Medical Ltd.) for the supraspinal stimulation. The Neuro Trac 4-Continence (Verity Medical Ltd.) stimulator allows one to set individual stimulation parameters and record them in the user´s programme. After thorough training on the use of equipment and providing detailed written indications for the performance of treatment, patients continued the therapy at home for 8 weeks, on average for 10 -15 minutes 2 to 3 times a day.
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