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MS research update – Pelvic floor training and electrical stimulation to treat bladder symptoms in women with MS – 4 April 2016

Summary

Bladder problems are one of the most common symptoms reported by people with multiple sclerosis and they can have a big impact on many aspects of life. This study investigated how effective two types of electrical stimulation treatments were for controlling bladder problems in women with MS who were already doing pelvic floor training.

30 women with relapsing remitting MS in Brazil took part in the study. They were split into three groups, all participants received pelvic floor muscle training, in addition the first group received a fake electrical stimulation that had no effect, the second group received intravaginal neuromuscular electrical stimulation and the third group received transcutaneous tibial nerve stimulation

The study found that in all groups bladder symptoms were improved although there were some additional benefits found from the pelvic floor training combined with intravaginal neuromuscular electrical stimulation.

Background

Bladder problems are one of the most common symptoms reported by people with multiple sclerosis and they can have a big impact on many aspects of life. Successful treatment is available and straightforward lifestyle changes can also make a real difference. As well as medications and devices, exercise and strengthening treatments can also be helpful in treating bladder problems. These include:

Pelvic floor muscle training (PFMT) – these are exercises that strengthen the pelvic floor which is a sheet of muscles that run from your pubic bone at the front to the base of your spine at the back and support the bladder and bowel.

Intravaginal neuromuscular electrical stimulation (NMES) – the pelvic floor muscles are exercised and strengthened by placing an electrical probe within the vagina.

Transcutaneous tibial nerve stimulation (TTNS) – is designed to indirectly stimulate the nerves that are responsible for bladder control. Small electrodes are placed on the skin by the ankle and electrical signals travelling along the nerves help to retrain bladder function.

This study investigated how effective NMES and TTNS treatments were for controlling bladder problems in women with MS who were already doing pelvic floor training.

How this study was carried out

30 women with relapsing remitting MS in Brazil took part in the study. They were randomly allocated to one of three groups:

  • Group 1 received pelvic floor training with a fake NMES treatment (although this used a probe and electrical current, it was not the correct signal to have an effect), so they did not know they were in the control group.
  • Group 2 received pelvic floor training and intravaginal NMES
  • Group 3 received pelvic floor training and TTNS.

Participants were trained how to do pelvic floor muscle exercises and instructed to do this set of exercises three times a day at home. They also attended the clinic for treatment with the electrical stimulators twice a week for 12 weeks.

Several assessments were performed before and after the 12 week study period, these included muscle strength tests, bladder tests (to check volume, flow rate, pressure, residual volumes etc) and three questionnaires that explored how bothered participants were by their bladder symptoms, how often they needed to urinate and the impact of the symptoms of their quality of life. Participants were also instructed how to perform a 24-hour pad test (which measures the amount of urine leakage) and keep a bladder diary of how often they needed to go day and night, if they experience urgency, incontinence, hesitancy or incomplete bladder emptying.

The three groups were similar in in terms of age, time since they had been diagnosed with MS, how long they had been experiencing bladder symptoms, EDSS score and how many babies they had.

What was found

The study found that in all groups bladder symptoms were improved: leakage was reduced, there was a significant decrease in the number of times participant’s experienced urgency, incontinence, hesitancy, incomplete bladder emptying and nocturia (needing to go to the toilet in the night). Improvements were also seen in the scores on the questionnaires that the participants completed showing that the treatments all also reduced the bother the symptoms caused and increased quality of life.

The group that received pelvic floor training and NMES had more improvements than the other groups when it came to muscle flexibility and relaxing.

What does it mean?

The study found that pelvic floor training with or without NMES or TTNS are effective treatment for improving bladder symptoms in women, although there were some additional benefits found from the pelvic floor training combined with NMES. This is apparently the first study to investigate the benefits of these treatments when combined with pelvic floor exercise. The authors do highlight the small numbers of women involved in the study so the results should be interpreted with caution. They did have 113 women who qualified for the study but only 30 agreed to take part, they suggest that more may have wanted to be involved it they did not have to travel to the clinic for treatment twice a week and could have had the treatment at home and others may have been unwilling to receive the treatments.

Lúcio A, Dʼancona CA, Perissinotto MC, et al.
Pelvic floor muscle training with and without electrical stimulation in the treatment of lower urinary tract symptoms in women with multiple sclerosis.
J Wound Ostomy Continence Nurs. 2016 Mar 23. [Epub ahead of print]
Abstract
Read the full text of this paper

More about getting help with bladder symptoms

Bladder symptoms are common in MS. Damage to areas of the spinal cord or brain that control the bladder can cause different types of problem:

  • urgency - a desperate urge to go to the toilet with little or no warning
  • frequency - needing the toilet more than eight times a day
  • hesitancy - difficulty in emptying the bladder
  • retention - a feeling of incomplete bladder emptying

You can read more about bladder symptoms in the A to Z of MS. You can also order our book on managing your bladder. It provides a very practical approach to managing bladder symptoms and includes comments and tips from people with MS who know what it is like to live with bladder problems. NHS Choices also have further information about pelvic floor exercises.

If you are experiencing bladder symptoms, you can speak to your MS nurse or GP who may refer you to continence services. These nurses specialise in helping people with bladder and bowel symptoms.

Although bladder or bowel symptoms can be hard to talk about, it is worth seeking support from health professionals and exploring what treatment options are available.

Research by topic areas...

Assessment tools

Cadavid D, Cohen JA, Freedman MS, et al.
The EDSS-Plus, an improved endpoint for disability progression in secondary progressive multiple sclerosis.
Mult Scler. 2016 Mar 22. [Epub ahead of print]
Abstract

Causes of MS

Yao G, Wang P, Luo XD, et al.
Meta-analysis of association between Helicobacter pylori infection and multiple sclerosis.
Neurosci Lett. 2016 Mar 23;620:1-7. [Epub ahead of print]
Abstract

Zhang P, Wang R, Li Z, et al.
The risk of smoking on multiple sclerosis: a meta-analysis based on 20,626 cases from case-control and cohort studies.
PeerJ. 2016;4:e1797.
Abstract
Read the full text of this paper

CCSVI

Torres C, Hogan M, Patro S, et al.
Extracranial venous abnormalities: a true pathological finding in patients with multiple sclerosis or an anatomical variant?
Eur Radiol. 2016 Mar 24. [Epub ahead of print]
Abstract

Co-existing conditions

Smith AE, Molton IR, Jensen MP.
Self-reported incidence and age of onset of chronic comorbid medical conditions in adults aging with long-term physical disability.
Disabil Health J. 2016 Feb 18. [Epub ahead of print]
Abstract

Diagnosis

Durhan G, Diker S, Has AC, et al.
Influence of cigarette smoking on white matter in patients with clinically isolated syndrome as detected by diffusion tensor imaging.
Diagn Interv Radiol. 2016 Mar 24. [Epub ahead of print]
Abstract
Read the full text of this paper (PDF)

Disease modifying drugs

Alping P, Frisell T, Novakova L, et al.
Rituximab versus fingolimod after natalizumab in multiple sclerosis patients.
Ann Neurol. 2016 Mar 31. [Epub ahead of print]
Abstract

Larochelle C, Metz I, Lécuyer MA, et al.
Immunological and pathological characterization of fatal rebound MS activity following natalizumab withdrawal.
Mult Scler. 2016 Apr 1. [Epub ahead of print]
Abstract

Poulos C, Kinter E, Yang JC, et al.
A discrete-choice experiment to determine patient preferences for injectable multiple sclerosis treatments in Germany.
Ther Adv Neurol Disord. 2016 Mar;9(2):95-104.
Abstract
Read the full text of this paper

He D, Zhang C, Zhao X, et al.
Teriflunomide for multiple sclerosis.
Cochrane Database Syst Rev. 2016 Mar 22;3:CD009882.
Abstract
Read the full text of this paper

Fox EJ, Wynn D, Coles AJ, et al.
Alemtuzumab improves neurological functional systems in treatment-naive relapsing-remitting multiple sclerosis patients.
J Neurol Sci. 2016 Apr 15;363:188-94.
Abstract
Read the full text of this paper

Zivadinov R, Hojnacki D, Bergsland N, et al.
Effect of natalizumab on brain atrophy and disability progression in multiple sclerosis patients over 5 years.
Eur J Neurol. 2016 Mar 21. [Epub ahead of print]
Abstract

Drugs in development

Ghasami K, Faraji F, Fazeli M, et al.
Interferon β-1a and atorvastatin in the treatment of multiple sclerosis.
Iran J Immunol. 2016 Mar;13(1):16-26.
Abstract

Greenberg SJ, Zivadinov R, Lee-Kwen P, et al.
Fludarabine add-on therapy in interferon-beta-treated patients with multiple sclerosis experiencing breakthrough disease.
Ther Adv Neurol Disord. 2016 Mar;9(2):105-17.
Abstract
Read the full text of this paper

Family

Razaz N, Tremlett H, Boyce T, et al.
Incidence of mood or anxiety disorders in children of parents with multiple sclerosis.
Paediatr Perinat Epidemiol. 2016 Mar 24. [Epub ahead of print]
Abstract
Read the full text of this paper

Other treatments

Provenzano DA, Williams JR, Jarzabek G, et al.
Treatment of neuropathic pain and functional limitations associated with multiple sclerosis using an MRI-compatible spinal cord stimulator: a case report with two year follow-up and literature review.
Neuromodulation. 2016 Mar 28. [Epub ahead of print]
Abstract

Marinelli L, Mori L, Canneva S, et al.
The effect of cannabinoids on the stretch reflex in multiple sclerosis spasticity.
Int Clin Psychopharmacol. 2016 Mar 21. [Epub ahead of print]
Abstract

Peyro Saint Paul L, Creveuil C, Heinzlef O, et al.
Efficacy and safety profile of memantine in patients with cognitive impairment in multiple sclerosis: a randomized, placebo-controlled study.
J Neurol Sci. 2016 Apr 15;363:69-76.
Abstract

Bitarafan S, Saboor-Yaraghi A, Sahraian MA, et al.
Effect of vitamin A supplementation on fatigue and depression in multiple sclerosis patients: a double-blind placebo-controlled clinical trial.
Iran J Allergy Asthma Immunol. 2016 Feb;15(1):13-9.
Abstract
Read the full text of this paper (PDF)

Paediatric MS

Krupp LB, Pohl D, Ghezzi A, et al.
Subcutaneous interferon β-1a in pediatric patients with multiple sclerosis: regional differences in clinical features, disease management, and treatment outcomes in an international retrospective study.
J Neurol Sci. 2016 Apr 15;363:33-8.
Abstract
Read the full text of this paper

Makhani N, Schreiner T.
Oral dimethyl fumarate in children with multiple sclerosis: a dual-center study.
Pediatr Neurol. 2016 Apr;57:101-4.
Abstract

Physical activity

Kalron A.
The correlation between symptomatic fatigue to definite measures of gait in people with multiple sclerosis.
Gait Posture. 2016 Feb;44:178-83.
Abstract

Prognosis

Martinez-Lapiscina EH, Arnow S, Wilson JA, et al.
Retinal thickness measured with optical coherence tomography and risk of disability worsening in multiple sclerosis: a cohort study.
Lancet Neurol. 2016 Mar 18. [Epub ahead of print]
Abstract

Provision of care

D'Amico E, Leone C, Patti F.
Disability may influence patient willingness to participate in decision making on first-line therapy in multiple sclerosis.
Funct Neurol. 2016 Jan-Mar;31(1):21-3.
Abstract

Psychological aspects

Edwards KA, Molton IR, Smith AE, et al.
The relative importance of baseline pain, fatigue, sleep and physical activity: predicting change in depression in adults with multiple sclerosis.
Arch Phys Med Rehabil. 2016 Mar 22. [Epub ahead of print]
Abstract

Rehabilitation

Ferreira GD, Costa AC, Plentz RD, et al.
Respiratory training improved ventilatory function and respiratory muscle strength in patients with multiple sclerosis and lateral amyotrophic sclerosis: systematic review and meta-analysis.
Physiotherapy. 2016 Mar 26. [Epub ahead of print]
Abstract

Monjezi S, Negahban H, Tajali S, et al.
Effects of dual-task balance training on postural performance in patients with multiple sclerosis: a double-blind, randomized controlled pilot trial.
Clin Rehabil. 2016 Mar 22. [Epub ahead of print]
Abstract

das Nair R, Martin KJ, Lincoln NB.
Memory rehabilitation for people with multiple sclerosis.
Cochrane Database Syst Rev. 2016 Mar 23;3:CD008754.
Abstract
Read the full text of this paper

Symptoms and symptom management

Phé V, Chartier-Kastler E, Panicker JN.
Management of neurogenic bladder in patients with multiple sclerosis.
Nat Rev Urol. 2016 Mar 31. [Epub ahead of print]
Abstract

Castel-Lacanal E, Gamé X, Clanet M, et al.
Assessment of a program to encourage the multidisciplinary management of urinary disorders in multiple sclerosis.
Neurourol Urodyn. 2016 Mar 29. [Epub ahead of print]
Abstract

Patel VP, Zambrana A, Walker LA, et al.
Distraction adds to the cognitive burden in multiple sclerosis.
Mult Scler. 2016 Mar 24. [Epub ahead of print]
Abstract

Vitamin D

Burton JM, Eliasziw M, Trufyn J, et al.
A prospective cohort study of vitamin D in optic neuritis recovery.
Mult Scler. 2016 Apr 1. [Epub ahead of print]
Abstract

Brola W, Sobolewski P, Szczuchniak W, et al.
Association of seasonal serum 25-hydroxyvitamin D levels with disability and relapses in relapsing-remitting multiple sclerosis.
Eur J Clin Nutr. 2016 Mar 30. [Epub ahead of print]
Abstract

Wergeland S, Myhr KM, Løken-Amsrud KI, et al.
Vitamin D, HLA-DRB1 and Epstein-Barr virus antibody levels in a prospective cohort of multiple sclerosis patients.
Eur J Neurol. 2016 Mar 21. [Epub ahead of print]
Abstract

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