ELECTRICAL STIMULATION OF THE TRANSCUTANEOUS

POSTERIOR TIBIAL NERVE FOR TREATING URINARY

INCONTINENCE DUE TO NEUROGENIC HYPERACTIVE

BLADDER IN MULTIPLE SCLEROSIS

Hellen Orlando Veloso, Karla de Castro Cardoso

State University of Goiás, Goiânia, GO, Brazil

Fabiana S. B. Perez, Luciana R. Tenório Peixoto

School of Medicine, University of Brasília, Brasília, DF, Brazil

Cristiano Jacques Miosso, Adson F. da Rocha

University of Brasília at Gama, Gama, DF, Brazil

Keywords: Electrical Stimulation, Multiple Sclerosis, Overactive Neurogenic Bladder and Posterior Tibial Nerve.

Abstract: This study evaluates the therapeutic effectiveness of Transcutaneous Electrical Nerve Stimulation (TENS)

of the posterior tibial nerve, for treating urinary incontinence (UI) due to detrusor overactivity (DO) in

patients with multiple sclerosis (MS). Five volunteers having positive cutaneous plantar reflexes and intact

innervation of the anterior tibial participated in the study. Individuals with a positive Babinski reflex were

excluded. We applied 10 sessions of TENS currents (20 Hz, 200 milliseconds, tetrapolar), over a period of 5

weeks (2 sessions per week). The treatment was monitored through a Urogynecology Physiotherapeutic

Assessment Questionnaire and by a Voiding Log. We observed a reduction in the average frequency of

miction, as well as decreased nocturia; also, the urge incontinence symptoms in the treated patients were

cleared up.

1 INTRODUCTION

Multiple sclerosis (MS) is a progressive multifocal

neurological demyelinating condition in the central

nervous system. It is characterized by exacerbations

and remissions, and is prevalent in young adults,

females and Caucasians (Coelho, 2009; Poser, 1986;

Lana-Peixoto, 2002; Grzesiuk, 2006; Mendes, 2000;

Diament and Cypel, 1996; Stephen, 1995). Despite

the unknown etiology of MS, the presence of

autoimmune factors triggering attacks on myelin

have been reported (O-Sullivan, 2004).

The symptomology of MS is multiple and

variable, and it can cause lesions from the medulla

to the cerebral cortex (Poser, 1986). Pyramidal signs

such as spasticity, hyperreflexia and the Babinski

reflex are common in those with MS (Hauser and

Goodin, 2008). The presence of this pathological

reflex indicates lesions on the pyramidal tracts,

compromising voluntary motor control modulation

(Souza and Figueiredo, 1995; Dantas, 1992).

Among the symptoms, sensory deficits and

bladder disorders frequently stand out. Loss of

vibratory perception in the lower limbs, paresthesia,

hypoesthesia, disturbance in position awareness,

dysesthesia, and trigeminal neuralgia hyperpathia

are commonly found among the sensations (O-

Sullivan, 2004). And with the evolution of the

pathology, the urgency or urinary incontinence (UI)

will affect most people with MS (Stephen, 1995).

Around 90% of those with MS display detrusor

hyperactivity (DH). Involuntary contraction of the

detrusor muscle causes the bladder to be filled

incompletely with a constant loss of urine (Coelho,

2009), causing further patient discomfort .

230

Orlando Veloso H., de Castro Cardoso K., S. B. Perez F., R. Tenório Peixoto L., Jacques Miosso C. and F. da Rocha A..

ELECTRICAL STIMULATION OF THE TRANSCUTANEOUS POSTERIOR TIBIAL NERVE FOR TREATING URINARY INCONTINENCE DUE TO

NEUROGENIC HYPERACTIVE BLADDER IN MULTIPLE SCLEROSIS.

DOI: 10.5220/0003792902300233

In Proceedings of the International Conference on Biomedical Electronics and Devices (BIODEVICES-2012), pages 230-233

ISBN: 978-989-8425-91-1

 2012 SCITEPRESS (Science and Technology Publications, Lda.)

Assuming the presence of nerve projections from

the posterior tibial nerve to the bladder, treatment

with TENS may decrease the frequency of UI

(Fischer-Sgrott, 2009). Transcutaneous Electrical

Nerve Stimulation (TENS), an electrotherapeutic

resource used in physiotherapy, uses a low

frequency current, with intensity adjustable from 0

to 50 mA; the wave form is asymmetrical biphasic;

and the used frequency is between 1 and 150 Hertz

(Hz) (Frampton, 1998; Agne, 2004).

The electrodes may be placed on the medial

region of the leg, stimulating motor and sensory

innervation. For someone with MS, sensory

innervation may be compromised, and the

physiotherapist will then adjust the intensity of the

current by observing the motor stimulation in the

muscle. The use of this technique may promote a

decrease in the detrusor’s involuntary contractions

(Maciel and Souto, 2009).

Another resource that the physiotherapist can use

is the visualization of the rhythmic flexions/bending

of the hallux, which indicates that the electrodes are

correctly positioned and confirms preserved motor

innervation (Maciel and Souto, 2009; Amarenco,

2003). However, for individuals positive for

Babinski’s reflex, establishing the appropriate

dosage of the therapeutic current is more difficult,

due to the incorrect motor modulation that they

present. In these cases, it may become impossible to

control the intensity of the current produced by the

electrostimulous device and its motor response.

2 MATERIAL AND METHODS

This study was carried out in the School of Clinical

Physiotherapy at the State University of Goiás

(Goiânia, Goiás, Brazil). The research protocol was

submitted to and approved by the Ethics and

Research Committee at the Federal University of

Goiás. We selected twelve volunteers having UI and

who had been diagnosed with MS. Seven were

female, five were male, six were white, three were

mixed-race or medium dark-skinned and three were

black. After signing the Informed Consent Form, the

individuals were submitted to a Physiotherapeutic

Evaluation questionnaire in Urogynecology from the

Federal University of São Paulo and presented a

Voiding Log for three days. Next, we conducted a

physical exam in order to evaluate the cutaneous

plantar reflex.

Volunteers with no pathological reflex had

electrodes attached along the posterior tibial nerve,

as seen in Figure 1, in order to detect if the

innervation was intact with the use of electrical

stimulation (NEURODYN TENS portable, Ibramed

Ltda.).

Figure 1: Positioning of the electrodes.

Eight individuals presented a normal cutaneous

plantar reflex and a positive response to posterior

tibial nerve electrical stimulation, and were then

included as participants in this study. Three patients

abandoned the study. Five people of both sexes and

aged between 33 and 42 years old were submitted to

10 sessions, twice a week, for 20 minutes of

treatment. The TENS parameters used were: 20 Hz

frequency, a pulse width of 200 milliseconds,

stimulation with two channels with four electrodes

positioned on the lower extremity. One electrode

was fixed to the posterior medial malleolus and the

other was fixed 10 centimeters above this (Figure 1).

The intensity parameter in the individuals with hyper

and normal sensitivity was dosed according to how

the patient felt; in the individuals with

hypersensitivity, the rhythmic flexes of the hallux

motor signal were used as the dosing parameter. The

maximum intensity used was 30 milliamperes, as a

safety criterion in the procedure.

3 RESULTS AND DISCUSSION

The results we present below are based on the

descriptive analysis of data collected by both the

evaluation questionnaires and the voiding log of the

volunteers. Through the physical examination, the

presence of detrusor hyperreflexia (DH) was

observed in all the volunteers.

The main complaints reported by the participants

before the treatment and after the electrical

stimulation treatment appear, respectively, in Table I

and Table II. We observe, based on Table II, an

ELECTRICAL STIMULATION OF THE TRANSCUTANEOUS POSTERIOR TIBIAL NERVE FOR TREATING

URINARY INCONTINENCE DUE TO NEUROGENIC HYPERACTIVE BLADDER IN MULTIPLE SCLEROSIS

231

improvement in the urge incontinence and urine

frequency symptomology after the electrical

stimulation treatment.

Table 1: Description of the main patient complaints before

before

: frequency and P

before

: proportion) and after (F

after

frequency and P

after

: proportion) the treatment.

Main Complaint F

before

(%) F

after

(%)

Urge Incontinence 3 37.5 - -

Urine Frequency 3 37.5 2 50

Urgency 2 25 2 50

Total 8 100 4 100

We also observed that the sensation of the

voiding act changed after the treatment. In Table II,

we present the list of analyzed sensations, and the

frequency at which they occurred. Observe that there

was a decrease in the frequency of most sensations;

in particular, symptoms such as pain, post-void

desire and urge incontinence were no longer

reported after the treatment.

Table 2: Sensation of the voiding act before (F

before

frequency and P

before

: proportion) and after (F

after

frequency and P

after

: proportion) the treatment.

Sensation of voiding act

before

(%) F

after

(%)

Burning 2 18 1 20

Residual sensation

2 18 1 20

Post-void desire 4 37 - -

Pain 1 9 - -

Comfort 1 9 3 60

Urge incontinence

1 9 - -

Total 11 100 5 100

In general, urinary incontinence treatment is

considered effective when episodes of urinary loss

are reduced by 50% (Schreiner, 2009). With respect

to this parameter, involuntary loss of urine onto

clothes was reported by only two patients. From

void log entries, the average loss of urine in these

patients before the treatment was 2 times and after

treatment it was 1 time. This reduction may be

explained by possible neuromodulation caused by

the TENS current.

Another analyzed result refers to the reduction in

voiding frequency during the day, as shown in

Figure 2.

The average frequency of visits to the bathroom

at night before the treatment was 4 times, and this

frequency reduced to 2 times after treatment. Studies

about the use of electrical stimulation treatment

suggest a reduction in nocturia, with 38% relief of

this symptom (Marques, 2008), 21% improvement

in nocturnal voiding (Govier, 2001). In a study

involving MS patients, there was an improvement in

nocturia in 75% of patients (Kabay, 2009).

12345

Individuals

Voiding frequency

Before

After



Figure 2: Voiding frequency during the day per

participant.

Finally, we observed an improvement in nocturia

in three patients, as shown in Figure 3.

12345

Individuals

Voiding frequency

Before

After



Figure 3: Voiding frequency during the night per

participant.

4 CONCLUSIONS

Individuals with multiple sclerosis (MS), urinary

incontinence, alteration in the sensitivity and

preserved posterior tibial innervation can safely

receive electrical stimulation treatment. We

evaluated the effect of this treatment on MS patients

with overactive bladders. Our results suggest that

this type of treatment can lead to a decrease in

bladder dysfunction symptoms, and thus improve

this individuals’ quality of life.

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