Chapter 1 28 the bladder and pelvic floor. The mechanisms of its effect are not fully elucidated, but stimulation of peripheral fibers transmits impulses to the sacral nerves and neuromodulates the lower urinary tract, rectum, and anal sphincters.88 It has been proven successful in the treatment of CAF, 89,90 although there is lack of related articles and data regarding this subject with methodological limitations. Posterior tibial nerve stimulation is not recommended in the Dutch guideline.82 Pelvic floor physical therapy Pelvic floor physical therapy (PFPT) is an important part of treatment of pelvic floor dysfunctions and includes strategies to optimize lumbopelvic and spinal function and to improve bowel, bladder, and sexual function.91,92 The aim of PFPT is to increase awareness and proprioception, to improve muscle relaxation and elasticity of the pelvic floor muscles, to restore abdominopelvic coordination, pelvic floor muscle function, rectal sensitivity and to reduce pain. 93,94 Interventions consist of education about pelvic floor musculature and related symptoms, behavioural modifications, exercises aimed at pelvic floor awareness and relaxation combined with soft-tissue manipulation and myofascial release.95-97 These pelvic floor soft-tissue techniques can be performed from external and internal in the pelvis. Dyssynergia and increased pelvic floor muscle tone can effectively be treated with PFPT including biofeedback therapy and/or electro galvanic stimulation,94,98-103 and are recommended in clinical guidelines.104,105 Biofeedback is a behavioral learning process that relies on operant conditioning; visual, auditory, or verbal feedback from instruments that measure anorectal activity.101 Several techniques can be used, solid-state manometry systems, surface electromyography, rectal balloons, and home devices. The aim is to improve muscle tone, voluntary contraction, and abdominopelvic coordination (abdominal push effort without excessive straining), to coordinate outward motion of the abdominal wall with relaxation of the pelvic floor and modulating rectal sensation.106 Manometry and rectal balloon training have the opportunity to display rectal and anal pressures, whereas surface electromyography provides information on the pelvic floor muscles.105 The feedback from the devices is used to identify the disordered function and used to guide the pelvic floor muscle exercises to learn how to transform and control the disordered function.101 Electro galvanic stimulation is used to improve muscle proprioception and relaxation of the pelvic floor muscles and is used as form of neuromodulation for pain relief.103,107-109
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