VOL: 99, ISSUE: 19, PAGE NO: 53
Julia Herbert, Grad Dip Phys, MCSP, SRP, is specialist continence physiotherapist, Bolton Primary Care Trust, and is also an independent practitionerIn March 1998, the Interprofessional Collaboration in Continence Care (ICCC) was formed. The group, which included specialist nurses and physiotherapists, recognised the overlapping roles of the two professions in continence care and decided there were various clinical issues that needed clarification and definition, including basic training requirements and core competencies. It was decided that neuromuscular electrical stimulation (NMES) would be the first therapeutic intervention to be considered.
In March 1998, the Interprofessional Collaboration in Continence Care (ICCC) was formed. The group, which included specialist nurses and physiotherapists, recognised the overlapping roles of the two professions in continence care and decided there were various clinical issues that needed clarification and definition, including basic training requirements and core competencies. It was decided that neuromuscular electrical stimulation (NMES) would be the first therapeutic intervention to be considered.
After lengthy debate, a consensus document has now been produced which is supported by the RCN Continence Forum and the Chartered Society of Physiotherapy. The document contains a list of the competencies that are expected of clinicians prior to their use of NMES.
Types of NMES
There are many different terms used to describe NMES and many types of equipment available to administer it. However, all of these have a common purpose - the stimulation of nerves and/or muscles for a therapeutic response. Muscle and nerve activity can be altered by the application of an electrical current.
Forms of NMES that are available for continence treatments include:
- Maximal stimulation;
- Low-frequency stimulation;
- Transcutaneous electrical nerve stimulation (TENS);
- Stoller afferent nerve stimulation (SANS);
- Intravesical electrical stimulation.
Faradism and interferential therapy were both previously used in the treatment of continence-related problems, but are no longer recommended. It is now believed that the parameters used in these methods of stimulation are no longer appropriate.
Electrostimulation is not intended as a treatment option on its own but as an integral part of a package of care provided by an experienced and knowledgeable practitioner.
Prerequisite professional training
Anyone performing NMES must have:
- A relevant health professional qualification that has led to state registration, for example registered general nurse (RN), chartered physiotherapist (MCSP) or state registered physiotherapist (SRP);
- Training in the assessment and physical examination (including perineal, vaginal and rectal examination) of patients with bladder and bowel dysfunction.
Any training programme in the use of NMES should include:
- Anatomy and pathophysiology of the genital, lower urinary and colorectal tracts - the practitioner should have an understanding of the normal anatomy and physiology, and the abnormalities and dysfunctions;
- Diagnosis - the practitioner should have knowledge of conditions appropriate to the use of NMES, such as urinary stress incontinence, the unstable (overactive) bladder, urge faecal incontinence and passive faecal incontinence;
- Basic scientific principles - prior to the use of NMES the practitioner must have knowledge of the basic scientific principles of electrical currents, physiological and therapeutic effects, contraindications and precautions, safe application of NMES and side-effects.
- NMES equipment maintenance - the practitioner should be aware of the need for annual maintenance checks, and there should be written records of maintenance and repairs. The practitioner should know how to carry out everyday checks necessary for the safe upkeep of the equipment and also have an awareness of the environmental considerations for its use;
- Documentation - the practitioner should document the assessment (including skin sensation) of the patient, that they have obtained informed consent from the patient, the stimulation parameters used for treatment, the goals and outcomes, and any adverse effects;
- Infection control - the practitioner must be aware of infection control issues in relation to the environment, the equipment, the patient and the practitioner;
- Provision of home treatment units - the practitioner should know how to assess the client for suitability for home treatment and how to select the appropriate equipment. The practitioner should also have written instructions for the patient and conditions of loan, and know how to check the equipment prior to use and on return.
It is expected that the training and education in these core competencies will be carried out by recognised experts with both clinical and theoretical evidence-based knowledge. It is envisaged that there will be some method of formal assessment of both the theory and practice to demonstrate an individual's competency.
After appropriate education and assessment it should be assumed that competency is maintained and that regular clinical practice is supported by documented evidence. However, this knowledge and competency will need to be updated in line with any valid or new research findings.
Laycock, J., Vodusek, D.B. (2002) Electrical Stimulation. In: Laycock, J., Haslam, J. (eds) Therapeutic management of incontinence and pelvic pain. London: Springer.
Fall. M., Lindstrom, S. (1991) Electrical stimulation: A physiologic approach to the treatment of urinary incontinence. Urologic Clinics of North America; 18: 2, 393-407.