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Johanna Biemans , MSc. PTNS ( Percutaneous tibial nerve stimulation) : an evaluation of it’s possibilities. Overview. Historical perspective Overactive bladder Sanyinjiao Needling concepts - PowerPoint PPT Presentation
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PTNS (Percutaneous tibial nerve stimulation):an evaluation of it’s possibilities
Johanna Biemans, MSc
5-12-2013Johanna Biemans, MSc. ASA TCM-Kongress 2013 1
Historical perspective
Overactive bladder Sanyinjiao Needling concepts The Needle App
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 2
Overview ASA-TCM Das Leben ab 40
Percutaneous Tibial Nerve Stimulation
PTNS
34-gauge needle inserting at Sp6
Other elektrode on area Sp4 or sole feet
Electric current 0-10mA/20Hz/motoric sens.
30 min, once weekly, 12 weeks.
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 3
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 4
b.Chr.2500-Sanyinjiao-2013 a.Chr. 2013 History
Riddle of Bagdad’s Batteries
Pain killing effect electric fish Ancient Greek
Needle like objects were found near some of the batteries.
Electric stim. = manual
stim.: 3 times in 30 min. stim. during 2 min.
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 5
Where it all started. McGuire et al, 1983 Electrical stimulation at Sp6 improves urgency and incontinence in people
with detrusor overactivity.
Stoller, 1998 EA on Sp6 in rats decreases c-fos protein in neural pathways that lead to
micturition centre while giving noxious stimuli.
Improvement blood supply pelvic floor.
Modulation of autonomous and somatic nerves.
SANS: Stoller Afferent Nerve Stimulation
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 6
Research mainly: -the Netherlands and Italy.
-overactive bladder -refractory patients2 promovendi:Dr. vanBalken and Dr. vanDoninck
Research
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 7
Results
Observational. 60-80% impr.on OAB symptoms
OAB OAB/IC0
20406080
100Stoller1999Klinger et al.2000Govier2001vanBalken2001VanDoninck2003Kolom2Kolom1
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 8
Implemented in Hospitals for refractory OAB.
Code for reimbursement. Submitted to Guidelines Notification: different from acupuncture
because of energy concept.
Introduced in Health Care
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 9
Inspiration
Conventional medicine
The proof.
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 10
Uroplasty brings Urgent PC to the market. Sponsoring two big trials.
Meanwhile in the U.S.
Randomized Trial of Percutaneous Tibial Nerve Stimulation Versus Sham Efficacy in the Treatment of Overactive Bladder Syndrome: Results From the SUmiT Trial.
Randomized Trial of Percutaneous Tibial Nerve Stimulation Versus Extended-Release Tolterodine: Results From the Overactive Bladder Innovative Therapy Trial(OrBIT).
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 11
OrBIT SumIT Global response assessment of OAB symptom improvement after 12 weeks of therapy
p=0,01
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
PTNS
Tolterodine
Results
p<0,001
0.0%10.0%20.0%30.0%40.0%50.0%60.0%
PTNS N=110Sham N=110
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 12
Stock exchange listed company with;
25 million dollar revenu 2013
Break-through Uroplasty Inc.
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 13
(overactive) bladder5-12-2013
Johanna Biemans, MSc. ASA TCM-Kongress 2013 14
Back to the origin
TCM/Bladder Lower burner: Regulations of fluids Fire Ming Men Ni Yg
heats the Sp cooks and
condensates At Lu level Bl. Function:
storage, drainage overflow
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 15
Pathogenic
Incontinence mainly through Qi Xu. Lower burner loses the upward assisting
function Qi Xu: lo/mi/Ni PE:damp/heat/cold
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 16
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 17
Lo Qi Xu- Loss of vaporising function Tonify Lo Qi: Bl 13 ,
DM 12 -Cycle fluids disturbed Tonify watercycle : Lo 7
Mi Qi Xu-Transformation disturbed Tonify Sp Qi St 36, RM 12, -Downward movement, bladder overload. Bl 20 Ki Qi Xu Yin Tonify Ki Qi Ki 3, RM 4,Sp6Yang Bl23,DM4,Ni7, RM4
General Bl23, tonify Ki Qi Bl28, tonify Bl Qi Bl53, idem RM1 Mg28
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 18
Segmental
RM1 Bl29,30,31,32, 33,34tot54 Wisselwerking
sympatisch en para-sympatisch/ somatisch
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 19
4 symptoms: frequency( > 8 times a day), urgency, incontinence, nocturia
Treatment: medication, bladdertraining, PTNS, botox, operation.
Prevalence: 29.8 million Americans >40yrs have bothersome OAB symptoms= highly prevalent.
Women>men.
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 20
Overactive bladder western perspective
SanyinjiaoSpecified
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 21
Traditional Chinese Medicine
Huang di nei tsjing ling stju: once Strongly weakened person to stop sweating. Pubmed: 369 hits
Sp6
Lower burner
Expels damp
Clears heat
Moves XueCalms shen
Tonicum Yin/Xue
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 22
Sp6: core point
Sp9: dampness
St 27 : damp bladder
RM 3: cool
Interstitiel cystites
RM 4: warm
Sp10: blood
Li 11: cool blood
Ki5/Rm 3: cool blood uterus
Regulate short cycle
St36: Qi/shen
Ht 7: shen
Ht 3: joy de vivre
Depression
Clinical decisions: poetry
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 23
Clinical desicions PTNS
Research Guidelines
Overactive bladderFecal incontinence
NICE guidelinesUS
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 24
Fixed point choice.
Clinical desicions PTNS
Hypothesis Theory
Could PTNS be supportive in sexual dysfunctions or impotence?
Could it calm an overactive bladder?
Blood flow pelvis Neurophysiological
changes.
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 25
Efficacy and Effectiveness of Percutaneous Tibial nerve Stimulation in the Treatment of Pelvic organ Disorders: A Systematic Review.
Neuromodulation, Technology at the Neural Interface, Jan/Feb 2013, Vol 16, No.1. pg 25-34.
J.M.A.E.Biemans MSc, M. van Balken, PhD
Open for research
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 26
Urologic Incontinence UrgeStressMixed
Pain Bladder pain/ICPelvic pain
Voiding obstruction Urinary retentionRectal Incontinence FecalGyneacological Menstrual Dysmenorhea
MenorrhagiaPain Chronic pelvic painSexual Vaginism
PGAS( Persistent genital arousal syndrome)Dyspareunia
Andrological Prostate Chronic ProstatitisIIIB/CPP
Sexual
(Possible) Indications PTNS
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 27
pacemakers or implantable defibrillators. patients prone to excessive bleeding. patients with nerve damage that could impact
either PTNS or pelvic floor function. patients who are pregnant or planning to become
pregnant during the duration of the treatment.
Risks: low. Most common side-effects are temporary and include mild pain or skin inflammation at or near the stimulation site.
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 28
Contra indications PTNS
Summarize?
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 29
Merging5-12-2013
Johanna Biemans, MSc. ASA TCM-Kongress 2013 30
Needling concepts
Su Wen: Acupuncture or ‘needling’ consists of the insertion of needles of various materials into particular points of the body.
Needles are from the yin-yang point of view, charged with the activity of Yin. Needles for the excess of Yang.
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 31
TCM
Earacupuncture
Neuromodulation
Triggerpoi
nt
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 32
Theoretical models
Other Models?
Implement?Discard?Replace?
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 33
Rethink concepts of needling?
Different theory/different needle manipulation.
Specific theory > specific disorders Scientific maturation> necessity to
differentiate
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 34
Scientific necessity
Differentiating5-12-2013
Johanna Biemans, MSc. ASA TCM-Kongress 2013 35
The Needle App
Johanna Biemans, MSc. ASA TCM-Kongress 2013
Practical App
Right theory-- Right Needle-- Right Technique-- right Condition
WM/EBM/TCM
Friendly for practitioner.First release: April 2014
5-12-2013 36
Thanx for your attention
5-12-2013Johanna Biemans, MSc.
ASA TCM-Kongress 2013 37