Tratamento da incontinência urinária de esforço por meio de eletroestimulação funcional dos músculos do assoalho pélvico: revisão sistemática de ensaios clínicos aleatorizados

Este estudo teve como objetivo verificar, através de uma revisão sistemática de ensaios clínicos aleatorizados, os benefícios da estimulação elétrica funcional endovaginal ou dos tratamentos conservadores às pacientes com incontinência urinária de esforço, e demonstrar qual modalidade de tratamento conservador apresenta melhores resultados na terapêutica dessas mulheres: a estimulação elétrica funcional endovaginal, em comparação com os cones vaginais ou a realização de exercícios perineais. Para tanto, foram realizadas buscas nas principais bases de dados científicos, por estudos que atendessem a pergunta da pesquisa, tipo de intervenção e tipo de participantes selecionados. Destes, foram selecionados 7 estudos que foram submetidos à análise dos revisores, que avaliaram os seguintes desfechos: episódios de perda urinária, quantificação das perdas urinárias através do pad-test, força da musculatura perineal, qualidade de vida, volume residual, capacidade cistométrica máxima, melhora dos sintomas, satisfação e cura. Todas as terapias pesquisadas apresentaram melhora dos sintomas da incontinência urinária de esforço; no entanto, segundo os desfechos avaliados, apresentaram diferença no resultado comparativo. Quanto às perdas urinárias, ao pad-test e à força da musculatura perineal, a realização dos exercícios pélvicos obteve os melhores resultados. Já a terapia por estimulação elétrica endovaginal e a terapia com os cones apresentaram resultados semelhantes, não sendo encontrada diferença significativa em nenhum dos desfechos analisados. De acordo com os achados obtidos nesta revisão sistemática, entendemos que o tratamento pela estimulação elétrica traz benefícios às pacientes com incontinência urinária de esforço. Os exercícios pélvicos demonstraram ser a terapia que reduz mais significativamente os sintomas ocasionados por esta condição

Hemodynamic response in one session of strength exercise with and without electrostimulation in heart failure patients: a randomized controlled trial

Background: Studies have investigated the influence of neuromuscular electrostimulation on the exercise/muscle capacity of patients with heart failure (HF), but the hemodynamic overload has never been investigated. The aim of our study was to evaluate the heart rate (HR), systolic and diastolic blood pressures in one session of strength exercises with and without neuromuscular electrostimulation (quadriceps) in HF patients and in healthy subjects. Methods: Ten (50% male) HF patients and healthy subjects performed three sets of eight repetitions with and without neuromuscular electrostimulation randomly, with one week between sessions. Throughout, electromyography was performed to guarantee the electrostimulation was effective. The hemodynamic variables were measured at rest, again immediately after the end of each set of exercises, and during the recovery period. Results: Systolic and diastolic blood pressures did not change during each set of exercises among either the HF patients or the controls. Without electrostimulation: among the controls, the HR corresponding to the first (85 ± 13 bpm, p = 0.002), second (84 ± 10 bpm, p < 0.001), third (89 ± 17, p < 0.001) sets and recuperation (83 ± 16 bpm, p = 0.012) were different compared to the resting HR (77 bpm). Moreover, the recuperation was different to the third set (0.018). Among HF patients, the HR corresponding to the first (84 ± 9 bpm, p = 0.041) and third (84 ± 10 bpm, p = 0.036) sets were different compared to the resting HR (80 ± 7 bpm), but this increase of 4 bpm is clinically irrelevant to HF. With electrostimulation: among the controls, the HR corresponding to the third set (84 ± 9 bpm) was different compared to the resting HR (80 ± 7 bmp, p = 0.016). Among HF patients, there were no statistical differences between the sets. The procedure was well tolerated and no subjects reported muscle pain after 24 hours. Conclusions: One session of strength exercises with and without neuromuscular electrostimulation does not promote a hemodynamic overload in HF patients. (Cardiol J 2011; 18, 1: 39-46)

Effects of neuromuscular electrostimulation in patients with heart failure admitted to ward

Background: Neuromuscular electrostimulation has become a promising issue in cardiovascular rehabilitation. However there are few articles published in the literature regarding neuromuscular electrostimulation in patients with heart failure during hospital stay. Methods: This is a randomized controlled pilot trial that aimed to investigate the effect of neuromuscular electrostimulation in the walked distance by the six-minute walking test in 30 patients admitted to ward for heart failure treatment in a tertiary cardiology hospital. Patients in the intervention group performed a conventional rehabilitation and neuromuscular electrostimulation. Patients underwent 60 minutes of electrostimulation (wave frequency was 20 Hz, pulse duration of 20 us) two times a day for consecutive days until hospital discharge. Results: The walked distance in the six-minute walking test improved 75% in the electrostimulation group (from 379.7 +/- 43.5 to 372.9 +/- 46.9 meters to controls and from 372.9 +/- 62.4 to 500 +/- 68 meters to electrostimulation, p<0.001). On the other hand, the walked distance in the control group did not change. Conclusion: The neuromuscular electrostimulation group showed greater improvement in the walked distance in the six-minute walking test in patients admitted to ward for compensation of heart failure.

Subcortical electrostimulation to identify network subserving motor control

Objectives: Recent anatomical-functional studies have transformed our understanding of cerebral motor control away from a hierarchical structure and toward parallel and interconnected specialized circuits. Subcortical electrical stimulation during awake surgery provides a unique opportunity to identify white matter tracts involved in motor control. For the first time, this study reports the findings on motor modulatory responses evoked by subcortical stimulation and investigates the cortico-subcortical connectivity of cerebral motor control. Experimental design: Twenty-one selected patients were operated while awake for frontal, insular, and parietal diffuse low-grade gliomas. Subcortical electrostimulation mapping was used to search for interference with voluntary movements. The corresponding stimulation sites were localized on brain schemas using the anterior and posterior commissures method. Principal observations: Subcortical negative motor responses were evoked in 20/21 patients, whereas acceleration of voluntary movements and positive motor responses were observed in three and five patients, respectively. The majority of the stimulation sites were detected rostral of the corticospinal tract near the vertical anterior-commissural line, and additional sites were seen in the frontal and parietal white matter. Conclusions: The diverse interferences with motor function resulting in inhibition and acceleration imply a modulatory influence of the detected fiber network. The subcortical stimulation sites were distributed veil-like, anterior to the primary motor fibers, suggesting descending pathways originating from premotor areas known for negative motor response characteristics. Further stimulation sites in the parietal white matter as well as in the anterior arm of the internal capsule indicate a large-scale fronto-parietal motor control network. Hum Brain Mapp, 2012. © 2012 Wiley Periodicals, Inc.

Transcutaneous electrostimulation for osteoarthritis of the knee

BACKGROUND: Osteoarthritis is the most common form of joint disease and the leading cause of pain and physical disability in the elderly. Transcutaneous electrical nerve stimulation (TENS), interferential current stimulation and pulsed electrostimulation are used widely to control both acute and chronic pain arising from several conditions, but some policy makers regard efficacy evidence as insufficient. OBJECTIVES: To compare transcutaneous electrostimulation with sham or no specific intervention in terms of effects on pain and withdrawals due to adverse events in patients with knee osteoarthritis. SEARCH STRATEGY: We updated the search in CENTRAL, MEDLINE, EMBASE, CINAHL and PEDro up to 5 August 2008, checked conference proceedings and reference lists, and contacted authors. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials that compared transcutaneously applied electrostimulation with a sham intervention or no intervention in patients with osteoarthritis of the knee. DATA COLLECTION AND ANALYSIS: We extracted data using standardised forms and contacted investigators to obtain missing outcome information. Main outcomes were pain and withdrawals or dropouts due to adverse events. We calculated standardised mean differences (SMDs) for pain and relative risks for safety outcomes and used inverse-variance random-effects meta-analysis. The analysis of pain was based on predicted estimates from meta-regression using the standard error as explanatory variable. MAIN RESULTS: In this update we identified 14 additional trials resulting in the inclusion of 18 small trials in 813 patients. Eleven trials used TENS, four interferential current stimulation, one both TENS and interferential current stimulation, and two pulsed electrostimulation. The methodological quality and the quality of reporting was poor and a high degree of heterogeneity among the trials (I(2) = 80%) was revealed. The funnel plot for pain was asymmetrical (P < 0.001). The predicted SMD of pain intensity in trials as large as the largest trial was -0.07 (95% CI -0.46 to 0.32), corresponding to a difference in pain scores between electrostimulation and control of 0.2 cm on a 10 cm visual analogue scale. There was little evidence that SMDs differed on the type of electrostimulation (P = 0.94). The relative risk of being withdrawn or dropping out due to adverse events was 0.97 (95% CI 0.2 to 6.0). AUTHORS' CONCLUSIONS: In this update, we could not confirm that transcutaneous electrostimulation is effective for pain relief. The current systematic review is inconclusive, hampered by the inclusion of only small trials of questionable quality. Appropriately designed trials of adequate power are warranted.

Spinal cord injury therapy through active learning

Therapy employing epidural electrostimulation holds great potential for improving therapy for patients with spinal cord injury (SCI) (Harkema et al., 2011). Further promising results from combined therapies using electrostimulation have also been recently obtained (e.g., van den Brand et al., 2012). The devices being developed to deliver the stimulation are highly flexible, capable of delivering any individual stimulus among a combinatorially large set of stimuli (Gad et al., 2013). While this extreme flexibility is very useful for ensuring that the device can deliver an appropriate stimulus, the challenge of choosing good stimuli is quite substantial, even for expert human experimenters. To develop a fully implantable, autonomous device which can provide useful therapy, it is necessary to design an algorithmic method for choosing the stimulus parameters. Such a method can be used in a clinical setting, by caregivers who are not experts in the neurostimulator's use, and to allow the system to adapt autonomously between visits to the clinic. To create such an algorithm, this dissertation pursues the general class of active learning algorithms that includes Gaussian Process Upper Confidence Bound (GP-UCB, Srinivas et al., 2010), developing the Gaussian Process Batch Upper Confidence Bound (GP-BUCB, Desautels et al., 2012) and Gaussian Process Adaptive Upper Confidence Bound (GP-AUCB) algorithms. This dissertation develops new theoretical bounds for the performance of these and similar algorithms, empirically assesses these algorithms against a number of competitors in simulation, and applies a variant of the GP-BUCB algorithm in closed-loop to control SCI therapy via epidural electrostimulation in four live rats. The algorithm was tasked with maximizing the amplitude of evoked potentials in the rats' left tibialis anterior muscle. These experiments show that the algorithm is capable of directing these experiments sensibly, finding effective stimuli in all four animals. Further, in direct competition with an expert human experimenter, the algorithm produced superior performance in terms of average reward and comparable or superior performance in terms of maximum reward. These results indicate that variants of GP-BUCB may be suitable for autonomously directing SCI therapy.

Eletroestimulação, exercícios dos músculos do assoalho pélvico e incontinência urinária

A incontinência urinária além de ser multifatorial com enorme complexidade terapêutica é um problema de ordem de saúde pública e que merece maior atenção, pois causa um imenso impacto negativo sobre a qualidade de vida das pessoas. São diversas as opções de tratamento da incontinência urinária, como os exercícios dos músculos do assoalho pélvico, tratamento com fármacos, injeção transuretral, e o esfíncter urinário artificial. A Sociedade Internacional de Continência recomenda como tratamento inicial os exercícios dos músculos do assoalho pélvico supervisionado, orientações de estilo de vida adequado, regimes urinários regulares, terapias comportamentais e medicação. A Revisão Sistemática desta Dissertação mostrou a necessidade de mais estudos com melhor qualidade metodológica para evidenciar o uso da eletroestimulação como intervenção eficaz no tratamento da incontinência urinária; O Estudo Transversal Retrospectivo, após a análise de 128 prontuários do Ambulatório de Fisioterapia Pélvica do Hospital Federal dos Servidores do Rio de Janeiro mostrou resultados significativos da Fisioterapia Pélvica para a redução da incontinência urinária e do impacto da incontinência urinária na vida diária destes pacientes. Por fim, o Experimento Controlado Randomizado, duplo cego, mostrou resultados significativos do uso da eletroestimulação associada aos exercícios dos músculos do assoalho pélvico como uma opção de tratamento conservador capaz de potencializar a continência urinária após a prostatectomia radical.

Método DeLorme versus Electroestimulação no fortalecimento muscular do quadricípete

Monografia apresentada à Universidade Fernando Pessoa para obtenção do grau de Licenciada em Fisioterapia

Effect of intravaginal electrical stimulation on pelvic floor muscle strength

The aim of this study was to evaluate the effect of intravaginal electrical stimulation (IES) on pelvic floor muscle (PFM) strength in patients with mixed urinary incontinence (MUI). Between January 2001 and February 2002, 40 MUI women (mean age: 48 years) were studied. Urge incontinence was the predominant symptom; 92.5% also presented mild stress urinary incontinence (SUI). Selection criteria were clinical history and urodynamics. Pre-treatment urodynamic study showed no statistical differences between the groups. Ten percent of the women in each group had involuntary detrusor contractions. Patients were randomly distributed, in a double-blind study, into two groups. Group G 1 (n=20), effective IES, and group G2 (n=20), sham IES, with follow-up at 1 month. The following parameters were studied: (1) clinical questionnaire, (2) examiner's evaluation of perineal muscle strength, (3) objective evaluation of perineal muscle by perineometry, (4) vaginal weight test, and (5) urodynamic study. The IES protocol consisted of three 20-min sessions per week over a 7-week period using a Dualpex Uro 996 at 4 Hz. There was no statistically significant difference in the demographic data of both groups. The number of micturitions per 24 h after treatment was reduced significantly in both groups. Urge incontinence, present in all patients before treatment, was reduced to 15% in G1 and 31.5% in G2 post-treatment. The subjective evaluation of PFM strength demonstrated a significant improvement in G1. Objective evaluation of PFM force by perineometer showed a significant improvement in maximum peak contraction post-treatment in both groups. In the vaginal weight test, there was a significant increase in average number of cone retentions post-treatment in both groups. With regard to satisfaction level, after treatment, 80% of the patients in G1 and 65% of the patients in G2 were satisfied. There was no statistically significant difference between the groups. There was a significant improvement in PFM strength from both effective and sham electrostimulation, questioning the effectiveness of electrostimulation as a monotherapy in treating MUI.

Intravaginal electrical stimulation: a randomized, double-blind study on the treatment of mixed urinary incontinence

Background the aim of this study was to compare effective and sham intravaginal electrical stimulation (IES) in treating mixed urinary incontinence. Methods. Between January 2001 and February 2002, 40 women were randomly distributed, in a double-blind study, into two groups: group G1 (n = 20), effective IES, and group G2 (n = 20), sham IES, with follow up at one month. Different parameters was studied: 1. clinical questionnaire, 2. body mass index; 3. 60-min pad test; 4. urodynamic study. The protocol of IES consisted of three 20-min sessions per week over a seven-week period. The Dualpex Uro 996 used a frequency of 4 Hz. Results. There was no statistically significant difference in the demographic data of both groups. The number of micturitions per 24 h after treatment was reduced significantly in both groups. Urge incontinence was reduced to 15% in G1 and 31.5% in G2; there was no significant difference between the groups. In the analog wetness and discomfort sensation evaluations were reduced significantly in both groups. The pretreatment urodynamic study showed no statistical difference in urodynamic parameters between the groups. Ten percent of the women presented involuntary detrusor contractions. In the 60-min pad test, there was a significant reduction in both groups. In regards to satisfaction level, after treatment, 80% of G1 patients and 65% of G2 patients were satisfied. There was no statistically significant difference between the groups. Conclusion. Significant improvement was provided by effective and sham electrostimulation, questioning the effectiveness of electrostimulation as a monotherapy.

Electroacupuncture analgesia in dogs: is there a difference between uni- and bi-lateral stimulation?

Objective To compare the analgesic effect of uni- and bi-lateral electroacupuncture (EA) in response to thermal and mechanical nociceptive stimuli and to investigate the cardiorespiratory, endocrine, and behavioral changes in dogs submitted to EA.Study design Prospective, randomized cross-over experimental study.Animals Eight adult, clinically healthy, cross-breed dogs, weighing 13 +/- 4 kg.Methods Dogs underwent electrostimulation at false acupoints (T-false); bilateral EA at acupoints, stomach 36, gall bladder 34 and spleen 6 (T-EA/bil); unilateral EA at the same points (T-EA/uni) or were untreated (T-control). All animals received acepromazine (0.05 mg kg(-1)) IV; and heart rate, pulse oximetry, indirect arterial blood pressure, respiratory rate, PECO2, rectal temperature, and plasma cortisol concentration were measured before, during, and after EA. Analgesia was tested using thoracic and abdominal cutaneous thermal and mechanical stimuli, and an interdigital thermal stimulus. Behavior was classified as calm or restless. Analysis of variance for repeated measures followed by Tukey's test was used for analysis of the data.Results There were no cardiorespiratory differences among the treatments. The cutaneous pain threshold was higher after EA, compared with false points. The latency period was shorter and analgesia was more intense in T-EA/bil than T-EA/uni, when both were compared with T-false and T-control. Six out of eight animals treated with EA were calm during treatment, and 5/8 and 4/8 of the T-false and T-control animals, respectively, were restless. Latency to interdigital thermal stimulation increased in T-EA/bil compared with the others. There was no difference in plasma cortisol concentrations among the treatments.Conclusions Bilateral EA produced a shorter latency period, a greater intensity, and longer duration of analgesia than unilateral stimulation, without stimulating a stress response.Clinical relevance Bilateral EA produces a better analgesic effect than unilateral EA.

Lactato sanguíneo na avaliação dos efeitos da peridural torácica em cães anestesiados pelo isoflurano

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Balão Térmico para Ablação Endometrial: Resultados Preliminares

Objetivos: os autores mostram a experiência preliminar com o uso do balão térmico para ablação do endométrio em pacientes com queixas de menorragia. Pacientes e Métodos: foram submetidas a este procedimento 20 pacientes. Após exame pélvico completo e ultra-sonografia endovaginal, todas as pacientes foram submetidas à histeroscopia diagnóstica com biópsia de endométrio para excluir causas de malignidade. Das 20 pacientes que se submeteram ao tratamento com balão térmico, 16 foram submetidas em regime ambulatorial com anestesia local. O procedimento teve duração de 8 minutos e 30 segundos. Resultados: duas das 20 pacientes mostraram-se insatisfeitas, mantendo o quadro hemorrágico inalterado, e 18 pacientes referiram melhora da sintomatologia. Não houve complicações do procedimento. Conclusões: o uso do balão térmico para ablação endometrial mostrou-se seguro e eficaz para o tratamento da menorragia de causa benigna.