PTNS Percutaneous tibial nerve stimulation an evaluation of

PTNS (Percutaneous tibial nerve stimulation): an evaluation of it’s possibilities � Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 1

Overview � Historical perspective � Overactive bladder � Sanyinjiao � Needling concepts � The Needle App ASA-TCM Das Leben ab 40 Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 2

Percutaneous Tibial Nerve Stimulation 34 -gauge needle inserting at Sp 6 Other elektrode on area Sp 4 or sole feet Electric current 0 -10 m. A/20 Hz/motoric sens. 30 min, once weekly, 12 weeks. PTNS Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 3

b. Chr. 2500 -Sanyinjiao-2013 a. Chr. 2013 History Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 4

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. Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 5

Where it all started. � Mc. Guire � et al, 1983 Electrical stimulation at Sp 6 improves urgency and incontinence in people with detrusor overactivity. � Stoller, 1998 � EA on Sp 6 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 Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 6

Research � Research mainly: -the Netherlands and Italy. -overactive bladder -refractory patients 2 promovendi: Dr. van. Balken and Dr. van. Doninck Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 7

Results � Observational. symptoms 100 Stoller 1999 80 Klinger et al. 2000 60 Govier 2001 40 van. Balken 2001 20 0 60 -80% impr. on OAB Van. Doninck 2003 OAB/IC Kolom 2 Kolom 1 Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 8

Introduced in Health Care � Implemented in Hospitals for refractory OAB. � Code for reimbursement. � Submitted to Guidelines � Notification: different from acupuncture because of energy concept. Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 9

Inspiration � Conventional medicine � The proof. Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 10

Meanwhile in the U. S. � Uroplasty brings Urgent PC to the market. � Sponsoring two big trials. Randomized Trial of Percutaneous Tibial Nerve Stimulation Versus Sham Efficacy in the Treatment of Overactive Bladder Syndrome: Results From the SUmi. T Trial. Randomized Trial of Percutaneous Tibial Nerve Stimulation Versus Extended-Release Tolterodine: Results From the Overactive Bladder Innovative Therapy Trial(Or. BIT). Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 11

Results � Or. BIT � Global response assessment of OAB symptom � improvement after 12 weeks of therapy 90. 0% 80. 0% 70. 0% 60. 0% 50. 0% 40. 0% 30. 0% 20. 0% 10. 0% Sum. IT 60. 0% 50. 0% p=0, 01 PTNS 40. 0% Tolterod ine 20. 0% PTNS N=110 30. 0% Sham N=110 10. 0% p<0, 001 Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 12

Break-through Uroplasty Inc. Stock exchange listed company with; 25 million dollar revenu 2013 Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 13

Back to the origin (overactive) bladder Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 14

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 Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 15

Pathogenic � Incontinence mainly through Qi Xu. � Lower burner loses the upward assisting function � Qi Xu: lo/mi/Ni � PE: damp/heat/cold Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 16

Lo Qi Xu -Loss of vaporising function -Cycle fluids disturbed Tonify Lo Qi: Bl 13 , DM 12 Tonify watercycle : Lo 7 Mi Qi Xu -Transformation disturbed -Downward movement, bladder overload. Yin Yang Tonify Sp Qi St 36, RM 12, Bl 20 Ki Qi Xu Tonify Ki Qi Ki 3, RM 4, Sp 6 Bl 23, DM 4, Ni 7, RM 4 Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 17

General � Bl 23, tonify Ki Qi � Bl 28, tonify Bl Qi � Bl 53, idem � RM 1 � Mg 28 Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 18

Segmental � RM 1 � Bl 29, 30, 31, 32, � 33, 34 tot 54 � Wisselwerking sympatisch en para-sympatisch/ � somatisch Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 19

Overactive bladder western perspective � 4 symptoms: frequency( > 8 times a day), urgency, incontinence, nocturia � Treatment: medication, bladdertraining, PTNS, botox, operation. � Prevalence: 29. 8 million Americans >40 yrs have bothersome OAB symptoms= highly prevalent. � Women>men. Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 20

Sanyinjiao Specified Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 21

Traditional Chinese Medicine Huang di nei tsjing ling stju: once � Strongly weakened person to stop sweating. � Pubmed: 369 hits � Expels damp Sp 6 Lower burner Clears heat Calms shen Moves Xue Tonicum Yin/Xue Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 22

Clinical decisions: poetry Sp 6: core point Sp 9: dampness Sp 10: blood St 36: Qi/shen St 27 : damp bladder Li 11: cool blood Ht 7: shen Ki 5/Rm 3: cool blood uterus Ht 3: joy de vivre Regulate short cycle Depression RM 3: cool Interstitiel cystites RM 4: warm Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 23

Clinical desicions PTNS Guidelines Research Fixed point choice. Overactive bladder Fecal incontinence NICE guidelines US Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 24

Clinical desicions PTNS � Could PTNS be supportive in sexual dysfunctions or impotence? � Could it calm an overactive bladder? Hypothesis � Blood flow pelvis � Neurophysiological changes. Theory Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 25

Open for research � 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, Ph. D Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 26

(Possible) Indications PTNS Urologic Incontinence Urge Stress Mixed Pain Bladder pain/IC Pelvic pain Voiding obstruction Urinary retention Rectal Incontinence Fecal Gyneacological Menstrual Dysmenorhea Menorrhagia Pain Chronic pelvic pain Sexual Vaginism PGAS( Persistent genital arousal syndrome) Dyspareunia Prostate Chronic Prostatitis. IIIB/CPP Andrological Sexual Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 27

Contra indications PTNS � 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. Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 28

Summarize? Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 29

Needling concepts Merging Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 30

� 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. Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 31

Theoretical models TCM Earacupuncture Neuromodulation Triggerpoint Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 32

Rethink concepts of needling? Discard? Implement? Replace? Other Models? Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 33

Scientific necessity � Different theory/different needle manipulation. � Specific theory > specific disorders � Scientific maturation> necessity to differentiate Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 34

The Needle. Differentiating App Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 35

Practical App Right theory-- Right Needle-- Right Technique- right Condition WM/EBM/TCM Friendly for practitioner. First release: April 2014 Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 36

Thanx for your attention Johanna Biemans, MSc. ASA TCM-Kongress 2013 5 -12 -2013 37