CLINICAL OPINION How to report electrotherapy parameters and procedures for pelvic floor dysfunction Angélica Mércia Pascon Barbosa1 & Nivaldo Antonio Parizotto2,3 & Cristiane Rodrigues Pedroni1 & Mariana Arias Avila3,4 & Richard Eloin Liebano3,4 & Patricia Driusso3,4 Received: 16 January 2018 /Accepted: 31 July 2018 /Published online: 24 August 2018 # The International Urogynecological Association 2018 Abstract Electrical stimulation is widely used for pelvic floor muscle dysfunctions (PFMDs), but studies are not always clear about the parameters used, jeopardizing their reproduction. As such, this study aimed to be a reference for researchers and clinicians when using electrical stimulation for PFMD. This report was designed by experts on electrophysical agents and PFMDwho determined all basic parameters that should be described. The terms were selected from the Medical Subject Headings database of controlled vocabulary. An extensive process of systematic searching of databases was performed, after which experts met and discussed on the main findings, and a consensus was achieved. Electrical stimulation parameters were described, including the physiological meaning and clinical relevance of each parameter. Also, a description of patient and electrode positioning was added. A consensus-based guideline on how to report electrical stimulation parameters for PFMD treatment was developed to help both clinicians and researchers. Keywords Consensus . Electric stimulation therapy . Electrodes . Parameters . Pelvic floor disorders Introduction Pelvic floor muscle dysfunction (PFMD) is a term applied to a wide variety of clinical conditions, including urinary inconti- nence, anal incontinence, pelvic organ prolapse, sensory and emptying abnormalities of the lower urinary tract, defecatory dysfunction, sexual dysfunction and chronic pain syndromes related to the pelvic organs [1]. The prevalence of PFMD is high in women and men and increases with age [2, 3]. These dysfunctions undermine quality of life [4] and cause problems involving significant healthcare costs [5, 6]. Physical therapy interventions have been considered the first-line treatment for stress urinary incontinence [7, 8]. It can be also effective for the treatment of the intestinal consti- pation [9] and fecal incontinence [9, 10], urgency urinary in- continence [11], sexual dysfunction symptoms [12, 13] and pelvic pain [14]. Among physical therapy modalities, electri- cal stimulation can be used as an adjuvant treatment with several purposes, such as muscle inhibition [15], muscle acti- vation [16–18] and analgesia [14]; electrical stimulation has been used to treat almost all kinds of PFMD, with different levels of evidence [19]. Nonetheless, scientific evidence is still not strong enough to determine the best parameters for each application. This difficulty may be related to differences in the reported parameters and the lack of others. Several studies on electrical stimulation as a therapy for pelvic floor dysfunction have been published in recent years [13, 17, 20–24], but most do not thoroughly describe the elec- trical stimulation parameters, such as the current and electrode type, pulse width, frequency, patient positioning, duration and number of sessions, and inclusion of other resources other * Angélica Mércia Pascon Barbosa angelicapascon@gmail.com 1 School of Philosophy and Sciences, Department of Physiotherapy and Occupational Therapy, São Paulo State University (UNESP), Av. Hygino Muzzi Filho, 737, Bairro: Mirante, Marília, SP CEP:17.525-900, Brazil 2 Post-Graduate Program of Biotechnology on Regenerative Medicine and Medical Chemistry, University of Araraquara, (UNIARA), Araraquara, SP, Brazil 3 Physical Therapy Post-Graduate Program, Federal University of São Carlos (UFSCar), São Carlos, SP, Brazil 4 Research Nucleus on Electrophysical Agents (Núcleo de Pesquisa em Agentes Eletrofísicos –NUPE), Federal University of São Carlos (UFSCar), São Carlos, SP, Brazil International Urogynecology Journal (2018) 29:1747–1755 https://doi.org/10.1007/s00192-018-3743-y http://crossmark.crossref.org/dialog/?doi=10.1007/s00192-018-3743-y&domain=pdf mailto:angelicapascon@gmail.com than electrical stimulation. This may generate a bias especially for systematic reviews as it may be difficult to synthesize and summarize results without complete information on parame- ters. Hence, standardization of how to report these parameters can make it easier to reproduce and interpret data from future studies. This kind of report has been published and extensive- ly used for other electrophysical agents, such as low-level laser therapy [25], and in a recent report on pelvic floor dys- function [26]. Having confirmed the need for accurate and complete reports on a wide range of technical and electrotherapeutic parameters, the objective of this article was to prepare a report to standardize the presentation of this information and to be a reference guide for recommendations for academics, clinicians and researchers to report the param- eters and physical procedures of electrotherapy used in patients with PFMD. Methods This literature review was performed to identify studies that have been published on the subject, detecting what kind of information was missing from those studies. Thus, the authors formed a working group to elaborate guidelines so that future studies will have more complete descriptions, allowing better study reproduction in clinical settings as well as research fa- cilities. All working group members who hold expertise in the areas of pelvic floor dysfunction (AMPB and PD) and elec- trotherapy (NAP, CRP, REL and MAA), participated in sev- eral meetings for brainstorming during which the design of this report was planned. During the meetings, all the authors provided terms and expressions normally used in the literature on their area. Then, the terms were grouped according to the order in which all items should be reported, as follows: pa- tient, equipment, surface electrode, vaginal/anal electrode, treatment, electrical pulse parameters, electrical burst param- eters and medium-frequency current parameters. Authors searched several databases (Embase, PubMed, Bireme, Scopus, Web of Science, Science Direct and Cochrane) from April to December 2017. Also, several books used in undergraduate physical therapy courses to teach about electrophysical agents were consulted [27–34]. The terms re- lated to the reporting of electrotherapy for PFMD were select- ed from the MeSH (Medical Subject Headings) database of controlled vocabulary. Each electronic database was searched from the earliest year available to identify relevant studies. Additional searching for omitted terms in existing terminolo- gy papers was performed. Existing definitions of established terms concerning pelvic floor dysfunction [26, 35–38] and electrotherapy [27–29, 31–34, 39–42] were used when avail- able, and agreement on definitions and clinical relevance was reached by a consensus. Next, the terms and definitions were assessed by experts (two in pelvic floor dysfunction and two in electrotherapy), and all suggestions were brought to the last meeting and discussed among all authors. The final version of each definition was unanimously determined. The next step consisted of summing up the information gathered during the literature review; the group chose to put information on two different tables to allow everyone working with electrotherapy for PFMD (from the under- graduate student to the professor and clinician) to have important information at hand during treatment planning. The authors decided on two tables, one focused on the electrotherapy parameters and the other describing every- thing that should be reported/ performed for the application of electrotherapy in PFMD. Results The authors developed two tables (Tables 1 and 2) based on the consensus reached during discussions. Table 1 shows the definitions of the parameters for electrotherapy with the clin- ical relevance for each parameter. Table 2 presents the results on how the use of electrical stimulation and its parameters should be described in studies involving patients with PFMD. Discussion Some of the most important aspects of the subject are discussed. The first and most important point is to determine whether the patient is eligible for electrotherapy treatment. Researchers and clinicians must make sure that all exclusion criteria for electrical stimulation use have been assessed, for example, pacemaker use or peripheral vascular diseases [27]. Another point is the conditions of the skin or mucosa to re- ceive the electrical stimulation. If, for example, the electrical stimulus will be delivered directly to the vaginal mucosa, counterindications to the use of a vaginal probe must be eval- uated. The main counterindications in this case are inflamma- tory processes, genitourinary infection or sexually transmitted diseases. Also, the clinician/researcher should be alert to the skin/mucosal integrity and obtain the patient’s consent before starting an intervention. A proper and accurate assessment of the pelvic floor muscles is mandatory to determine the most appropriate kind of treatment (and of electrical stimulation) or clinical trial design. This kind of assessment must be per- formed by specially trained healthcare professional (for exam- ple, physical therapists, nurses, physicians, etc.) to provide consistency and accuracy. Clinical conditions of each patient or participant should be respected, and, once again, the thera- pist or researcher must consider the indications and counterindications for electrical stimulation use. The benefit of the application of electrical stimulation un- der some circumstances remains unclear and needs special 1748 Int Urogynecol J (2018) 29:1747–1755 Table 1 Definitions and clinical relevance of each electrotherapy parameter as agreed upon by the authors Parameter Description Clinical relevance Type of current (direct, alternating or pulsed) Direct current is at the most basic level continuous and flows in only one direction; alternating is a current that passes in one direction and then another. Pulsed current is the current (direct or alternating) in which there is a gap between successive pulses [33] The direct current can be thought as of an Binfinite pulse duration;^ clinically, it is used for iontophoresis. The alternating current is used mainly for innervated muscle contraction and sensory stimulation, and the pulses are joined and continuous; however, from the point of view of nerve excitation, the alternating current/direct current distinction is irrelevant. The pulsed current is distin- guished from the alternating current because pulses are separated. Thismeans less energymay be delivered to the tissue when using this type of current [33] Current amplitude (in A, mA or μA [34]; alternatively, in V, mVor μV [32]) Magnitude of current with reference to the zero-current baseline at any one moment It can be referred to as the intensity of stimulation, which explains why controls on clinical generators that regulate the amplitude of induced current are often labeled Bintensity^ [32] Increasing current amplitude will increase the amount of energy one delivers to the tissues under the electrode. It contributes the sensory or motor response the electrical current produces. The current amplitude is one of the determinants of torque production when using neuromuscular electrical stimulation. Increasing the current amplitude increases the percentage of muscle activated; increasing the current amplitude results in a proportional increase in the torque produced and the size of the activated cross-sectional area of the stimu- lated muscle [43] Current polarity Monophasic pulse: the charged particles move in only one direction [30], known as polar current Biphasic pulse: charged particles move in one direction and then in the opposite direction [30], known as nonpolar current If the current is polar, physiological effects will include alterations in the cell membrane permeability, causing different responses under positive (anode) and negative (cathode) electrodes [33]. For example, a marked hy- peremia is usually expected under the cathode and a decreased nerve excitability is expected under the anode [33] Pulse duration (in μs or ms, [34]) The elapsed time between the beginning and end of all phases in a single pulse; on clinical stimulators, the pulse duration is often incorrectly labeled Bpulse width^ [30, 32] The greater the pulse duration, the greater the skin impedance and the greater the patient’s discomfort. Increasing pulse duration has been shown to increase the charge of the pulse and motor unit recruitment [44]. Altering the pulse duration is dependent on the patient’s comfort and desired therapeutic effect; however, pulses with too short duration are inefficient Pulse frequency (in Hz or pulses per second, pps) The number of pulse cycles generated per unit of time for pulsed current [30, 32, 34] Frequency of the pulses has been studied extensively because of its important role in determining the torque development and controlling muscle fatigue. Increasing the frequency results in a sigmoidal increase in torque production but concurrently accelerates muscle fatigue [43, 44] Waveform shape (rectangular, square, triangular, sawtooth or spike [32]). Geometric shape of the pulse as it appears on the graph of current (or voltage) versus time Little clinical research has examined the clinical effect of using different pulse shapes; previous study showed that there were individual differences in preferences for three different waveforms of sinusoidal, sawtooth and square symmetric biphasic waveforms and no particular waveform that was either the least or most comfortable to the patient during neuromuscular electrical stimulation [45] Stimulation mode (when using more than one channel) Reciprocal, asynchronous or sequential Channels operate in a simultaneous or alternating fashion, per set duty cycle. In sequential stimulation, multiple stimulation channels are used (usually, to separately activate multiple synergistic muscles), thereby allowing motor units to rest when the corresponding stimulation channel is not active [46]. Asynchronous stimulation also uses multiple stimulation channels; however, the stimulus pulses are delivered in an interleaved manner so that lower stimulation frequencies are achieved at each stimulation channel while retaining a high composite stimulation frequency [46] Int Urogynecol J (2018) 29:1747–1755 1749 attention. For example, no studies were found on the effects of transcutaneous electrical stimulation on ovarian hormones or on users of intrauterine hormone devices. The use of electrical stimulation during pregnancy is still controversial; while the recommendation is to avoid neuromuscular electrical stimula- tion over the lower back, pelvis and abdomen [53], because it can increase uterine contractility in nonpregnant women [54], other studies have shown positive effects of TENS for low back pain during pregnancy with no harm to fetal formation [55, 56]. The use of electrical stimulation during labor and delivery is well established [57–60], while the form of appli- cation (transcutaneous versus vaginal stimulation) remains unclear. Several studies have been found on the effects of electrical stimulation in the postpartum period, but most of them are experimental and related to direct brain/nerve stim- ulation. Two studies have reported good results for electrical stimulation in the postpartum period after vaginal delivery [61, 62] and cesarean section [61]. They used current deliv- ered through the skin [61] or intravaginally [62], and both reported pain reduction. No reports on pelvic floor nerve dam- age affecting electrical stimulation were found. Nonetheless, it is not common to apply electrical stimulation when sensitive nerves have been damaged as this may interfere with the cur- rent amplitude delivered to the tissue. Users of electrotherapy for PFMD should be alert to the correct nomenclature for the electrical stimulation modality to be used. Transcutaneous electrical stimulation (TES) can be divided into several forms of use. Transcutaneous electrical nerve stimulation (TENS) involves a generic application of electrical currents across the intact surface of the skin to stim- ulate the peripheral nerves to produce various physiological effects [63]. Neuromuscular electrical stimulation (NMES) is defined as the application of an electric current using elec- trodes placed on skeletal muscles with the main objective to produce muscle contraction by activating intramuscular nerve branches for the purpose of restoring a degree of control over an abnormal or absent muscle function [64, 65]; when an electrically induced contraction is performed to produce a functional movement, this is called functional electrical stim- ulation (FES). Usually, TENS and NMES are the most used modalities for treating PFMD. Recommendations on safe handling of devices and for pa- tients must be followed to minimize the risk of patient injury [27]. Also, each country has specific guidelines for mainte- nance and inspection that should be respected. In most coun- tries, the required maintenance is annual to avoid injuries or discomfort to patients and device failures. Operation manuals, models and serial numbers as well as the inspection certifi- cates need to be updated. Regarding patient safety, metal parts (present in the connectors) must not be in contact with the patient’s skin to avoid local irritation or burns [28]. Hence, checking the integrity of the connectors is important for safe therapy. Electrode configuration needs special attention. Electrode placement should be determined by the target tissue. For ex- ample, if the target is muscle tissue, both electrodes must be placed over the same muscle belly; if the target tissue is a nerve, the electrodes should be placed along its path or at least one electrode placed where the nerve is more superficial (nerve motor point) and another electrode over the target mus- cle. Another topic is the interelectrode distance as the greater the distance the deeper the electrical current penetration in the tissue [29]. Usually, the distance should not be less than the surface area of the smallest electrode used [30]. Therapists Table 1 (continued) Parameter Description Clinical relevance Medium-frequency alternating current parameters Carrier frequency (in Hz or kHz) Frequency of underlying alternating current waveform in the burst Medium frequencies are used to diminish the impedance offered by the skin and subcutaneous tissues, turning the current more comfortable to the patient. Thus, by diminishing skin impedance, the discomfort normally incurred by traditional low-frequency currents is re- duced [33, 47] Burst The generation of 2 or more consecutive pulses or cycles separated (by burst interval) from the next series of consecutive pulses or cycles The burst duration has a role in torque production, discomfort, and fatigue [48, 49] Burst frequency or modulation Frequency at which bursts are generated This parameter focuses on the fatigue possibilities of muscles if the frequency is high (> 50 or 60 Hz). In low frequencies we have good recruitment of nervous fibers (between 20 and 50 Hz), and in very low frequencies (2–10 Hz) the nervous fibers relax the muscle fibers) Burst duty cycle Burst duty cycle of medium-frequency alternating current, expressed as a percentage, can be defined as the ratio of the burst duration to the total time of the cycle (burst length and interburst interval) [48] Burst duty cycle, similarly to burst duration, has an impact on torque production, discomfort, and fatigue [48, 49] 1750 Int Urogynecol J (2018) 29:1747–1755 Table 2 Description of each parameter that needs to be reported in studies using electrotherapy Item Parameter Description Patient Positioning: describe in which position patient received the electrical stimulation Lithotomy, modified lithotomy, prone or supine, seated or standing position, or other Use of support to patient’s accommodation Furniture/device in which patient is positioned (chair, ball, litter) Skin/mucosa preparation: describe how skin or mucosa was prepared to receive the electrodes Skin hygiene Trichotomy Pelvic floor muscle assessment Complete description on the method of assessment of pelvic floor muscles (if more than one method was used, describe all). Describe as suggested by [26, 36] Vaginal inspection, vaginal palpation (describe the scale used: Modified Oxford Grading Scale [50], PERFECT Scheme [50], Brink’s Scale [51], Ortiz’s Scale [52], etc.), manometry, dynamometry, electromyography, ultrasonography Device Complete device description Commercial name, brand and model Manufacturer’s country Periodic calibration (if performed) Surface electrode Electrode model Brand Manufacturer’s country Electrode placement Electrode location Orientation over muscle or fiber direction, anatomical references used to place the electrodes Distance between electrodes Distance from the center of one electrode to the other Material Metal, carbon, self-adhesive Interface material (between skin and electrodes): describe if any kind of interface material was used Liquid, gel or sticky gel type Size and format In cm, diameter or width × length Format: square, rectangular, circular Number of channels used for stimulation Describe number of channels (number of pairs of electrodes). If two or more, describe how each channel was located in relation to the other(s) Anal or vaginal electrode Electrode model Brand Manufacturer’s country Probe dimensions and format Total length Circumference Format: cylindrical, plane, conical Format and placement of conductive plates Number of conductive rings Distance between conductive rings Format: horizontal, vertical, relation to the probe Anatomical placement Depth of probe insertion into the vagina Anatomical reference to place probe Treatment Electrical stimulation duration (in each session) Time (in minutes) or number of contractions Therapy duration Number of sessions in which electrical stimulation was applied Interval between sessions Number of hours or days held between sessions Pelvic floor muscle status: whether the patient performed voluntary contraction along with electrical stimulation must be described If contraction was performed simultaneously to the electrical stimulation, describe: protocol (sustained contraction time, rest time, duration of whole treatment) and presence of verbal encouragement Patient physical activity status Describe if patient was resting or performing other physical activity while receiving the electrical stimulation (for example, on a stationary bicycle) Patient’s discomfort report Discomfort assessment during treatment Instrument used to assess discomfort (self-report, visual analog scale, etc.) Presence of reported/observed collateral effects Any reported or observed collateral effects during physical therapy treatment need to be described: major discomfort after treatment session end, skin burn or rash, etc. Int Urogynecol J (2018) 29:1747–1755 1751 should be aware of the size of electrodes. When too small, they might not be effective since the large current spreads within the fat layer and the current does not easily reach the deeper lying motor nerves [42]. Another effect of small elec- trodes is the generation of high current densities, which may be uncomfortable or even painful [40]. It is important to de- scribe the number of pairs of electrodes to inform the number of different structures treated during the same application. We currently find a wide variety of electric generators used for clinical purposes. The choice of electrical generator de- pends on the therapist experience [31] as well as how much the therapist can change the parameters to achieve the ideal current for the desired effect, in accordance with evidence- based practice. To have the minimum conditions to properly program an electrical stimulation treatment, the therapist should be able to select and modulate the frequency, pulse Table 2 (continued) Item Parameter Description Patient’s adherence to treatment Percentage of adherence to treatment (number of effective sessions/number of planned sessions) Combined treatment: describe any kind of combined therapy performed simultaneously to the electrical stimulation Home exercises, exercise sessions (without electrical stimulation), medications, education sessions or any other kind of therapy used— describe each therapy thoroughly Patient education: describe all educational sources and devices used to educate the patient about the pelvic floor muscles and dysfunctions and about treatments proposed. Patient’s education level also needs to be described Verbal explanation Anatomical models Drawings and pictures Performance corrections Telephone follow-up Motivational interviewing Physical therapist involvement with the patient (PT reminds patient about home exercises, etc.) Outcome: describe which variable is the primary outcome and the methods used to evaluate the outcome For scientific studies: Pelvic floor muscle function Urinary loss Cure Quality of life For clinical practice: Clearly state the main physical therapy objective Electrical pulse parameters Current type Continuous, alternating or pulsed Amplitude Electrical current amplitude (mA or V). Describe if stimulation was performed on sensory or motor levels Pulse duration Pulse duration in μs or ms Current frequency Frequency; describe in Hz or pps Waveform Describe waveform: rectangular (square), sinusoidal, triangular, etc. Polarity (biphasic or monophasic) If the current is pulsed, specify if monophasic or biphasic Burst parameters T ON/T OFF For stimulation on the motor level, describe contraction and relaxation times (in s) for each contraction Rise and decay Describe if rise and decay times (in s) were used Modes Stimulation mode: reciprocal, synchronic or sequential Modulation: describe if any kind of modulation was applied to the current Variation of amplitude, pulse duration or frequency during the stimulation time Medium-frequency currents Commercial current name Russian Interferential Aussie, etc. Carrier frequency Describe carrier frequency (in Hz or kHz) Modulation frequency Describe modulation frequency or burst frequency (in Hz) Burst duty cycle Describe burst duration and interburst interval (in ms) or duty cycle (in percentage) 1752 Int Urogynecol J (2018) 29:1747–1755 duration and amplitude. The device needs to provide informa- tion about the wave form, treatment time, T-on/T-off, rise and decay times when applicable [28, 32]. The clinician or re- searcher needs practice and knowledge of parameter controls so that he/she can ensure that they are applied to achieve the proposed goals. Also, clinical studies on electrical stimulation for PFMD should describe the parameters and procedures used in detail to enable the reproducibility of the work and comparison between different studies. Conclusions From the results of this article, we can conclude that it was possible to successfully elaborate the reporting of electrother- apy parameters and procedures for pelvic floor dysfunction. We recommend recognition of these standards in written pub- lications related to the use of electrotherapy in pelvic floor dysfunctions and the results of this report. We hope that use of the present report will assist researchers and professionals who work toward rehabilitation of pelvic floor dysfunctions, allowing the parameters to be adequately and complete- ly described, thus facilitating better reproducibility of the methods used, a critical analysis of the results ob- tained with the method used and advancement of the knowledge in this area. Compliance with ethical standards Conflicts of interest None. References 1. Bump RC, Norton PA. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin N Am. 1998;25:723–46. 2. Sung VW, Hampton BS. Epidemiology of pelvic floor dysfunction. Obstet Gynecol Clin N Am. 2009;36:421–43. 3. Sharma A, Yuan L, Marshall RJ, et al. Systematic review of the prevalence of faecal incontinence. Br J Surg. 2016;103:1589–97. https://doi.org/10.1002/bjs.10298. 4. Dedicação ACA, Haddad M, Saldanha MMES, Driusso P. Comparison of quality of life for different types of female urinary incontinence. Brazilian J Phys Ther. 2009;13:116–22. https://doi. org/10.1590/S1413-35552009005000014. 5. RichardsonML, Sokol ER. A cost-effectiveness analysis of conser- vative versus surgical management for the initial treatment of stress urinary incontinence. Am JObstet Gynecol. 2014;211(5):565.e1–6. https://doi.org/10.1016/j.ajog.2014.07.006. 6. Burge E, Monnin D, Berchtold A, Allet L. Cost-effectiveness of physical therapy only and of usual care for various health conditions: systematic review. Phys Ther. 2016;96:774–86. https://doi.org/10.2522/ptj.20140333. 7. Dumoulin C, Hay-Smith J, Habée-Séguin GM, Mercier J. Pelvic floor muscle training versus no treatment, or inactive control treat- ments, for urinary incontinence in women: a short versionCochrane systematic review with meta-analysis. Neurourol Urodyn. 2015;34: 300–8. https://doi.org/10.1002/nau.22700. 8. Paiva LL, Ferla L, Darski C, et al. Pelvic floor muscle training in groups versus individual or home treatment of women with urinary incontinence: systematic review and meta-analysis. Int Urogynecol J. 2017;28:351–9. https://doi.org/10.1007/s00192-016-3133-2. 9. Jarrett MED, Mowatt G, Glazener CMA, et al. Systematic review of sacral nerve stimulation for faecal incontinence and constipation. Br J Surg. 2004;91:1559–69. https://doi. org/10.1002/bjs.4796. 10. Horrocks EJ, Thin N, Thaha MA, et al. Systematic review of tibial nerve stimulation to treat faecal incontinence. Br J Surg. 2014;101: 457–68. 11. Booth J, Connelly L, Dickson S, et al. The effectiveness of trans- cutaneous tibial nerve stimulation (TTNS) for adults with overac- tive bladder syndrome: a systematic review. Neurourol Urodyn. 2017. https://doi.org/10.1002/nau.23351. 12. Rosenbaum TY, Owens A. The role of pelvic floor physical therapy in the treatment of pelvic and genital pain-related sexual dysfunc- tion. J Sex Med. 2008;5:513–23. https://doi.org/10.1111/j.1743- 6109.2007.00761.x. 13. Morin M, Carroll M-S, Bergeron S. Systematic review of the effectiveness of physical therapy modalities in women with provoked Vestibulodynia. Sex Med Rev. 2017;5:295–322. https://doi.org/10.1016/j.sxmr.2017.02.003. 14. Bonder JH, Chi M, Rispoli L. Myofascial pelvic pain and related disorders. Phys Med Rehabil Clin N Am. 2017;28: 501–15. https://doi.org/10.1016/j.pmr.2017.03.005. 15. Sluka KA, Walsh D. Transcutaneous electrical nerve stimulation: basic science mechanisms and clinical effectiveness. J Pain. 2003;4: 109–21. https://doi.org/10.1054/jpai.2003.434. 16. Hatem SM, Saussez G, della Faille M, et al. Rehabilitation of motor function after stroke: a multiple systematic review focused on techniques to stimulate upper extremity recovery. Front Hum Neurosci. 2016;10:442. https://doi.org/10.3389/ fnhum.2016.00442. 17. Bo K, Talseth T, Holme I. Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ. 1999;318:487–93. https://doi.org/10.1136/bmj.318. 7182.487. 18. Goode PS, Burgio KL, Locher JL, et al. Effect of behav- ioral training with or without pelvic floor electrical stimu- lation on stress incontinence in women: a randomized con- trolled trial. JAMA. 2003;290:345–52. https://doi.org/10. 1001/jama.290.3.345. 19. Thüroff JW, Abrams P, Andersson KE, et al. EAU guidelines on urinary incontinence. Eur Urol. 2011;59:387–400. https://doi.org/ 10.1016/j.eururo.2010.11.021. 20. Spruijt J, Vierhout M, Verstraeten R, et al. Vaginal electrical stim- ulation of the pelvic floor: a randomized feasibility study in urinary incontinent elderly women. Acta Obstet Gynecol Scand. 2003;82: 1043–8. 21. Schreiner L, dos Santos TG, Knorst MR, da Silva Filho IG. Randomized trial of transcutaneous tibial nerve stimulation to treat urge urinary incontinence in older women. Int Urogynecol J. 2010;21:1065–70. https://doi.org/10.1007/ s00192-010-1165-6. 22. Schreiner L, dos Santos TG, de Souza ABA, et al. Electrical stim- ulation for urinary incontinence in women: a systematic review. Int Braz J Urol. 2013;39:454–64. https://doi.org/10.1590/S1677-5538. IBJU.2013.04.02. 23. Moroni R, Magnani P, Haddad J, et al. Conservative treat- ment of stress urinary incontinence: a systematic review with meta-analysis of randomized controlled trials. Rev Bras Int Urogynecol J (2018) 29:1747–1755 1753 https://doi.org/10.1002/bjs.10298 https://doi.org/10.1590/S1413-35552009005000014 https://doi.org/10.1590/S1413-35552009005000014 https://doi.org/10.1016/j.ajog.2014.07.006 https://doi.org/10.2522/ptj.20140333 https://doi.org/10.1002/nau.22700 https://doi.org/10.1007/s00192-016-3133-2 https://doi.org/10.1002/bjs.4796 https://doi.org/10.1002/bjs.4796 https://doi.org/10.1002/nau.23351 https://doi.org/10.1111/j.1743-6109.2007.00761.x https://doi.org/10.1111/j.1743-6109.2007.00761.x https://doi.org/10.1016/j.sxmr.2017.02.003 https://doi.org/10.1016/j.pmr.2017.03.005 https://doi.org/10.1054/jpai.2003.434 https://doi.org/10.3389/fnhum.2016.00442 https://doi.org/10.3389/fnhum.2016.00442 https://doi.org/10.1136/bmj.318.7182.487 https://doi.org/10.1136/bmj.318.7182.487 https://doi.org/10.1001/jama.290.3.345 https://doi.org/10.1001/jama.290.3.345 https://doi.org/10.1016/j.eururo.2010.11.021 https://doi.org/10.1016/j.eururo.2010.11.021 https://doi.org/10.1007/s00192-010-1165-6 https://doi.org/10.1007/s00192-010-1165-6 https://doi.org/10.1590/S1677-5538.IBJU.2013.04.02 https://doi.org/10.1590/S1677-5538.IBJU.2013.04.02 Ginecol Obstet/RBGO Gynecol Obstet. 2016;38:097–111. https://doi.org/10.1055/s-0035-1571252. 24. Scaldazza CV, Morosetti C, Giampieretti R, et al. Percutaneous tibial nerve stimulation versus electrical stimulation with pelvic floor muscle training for overactive bladder syndrome in women: results of a randomized controlled study. Int Braz J Urol. 2017;43: 121–6. https://doi.org/10.1590/s1677-5538.ibju.2015.0719. 25. Jenkins PA, Carroll JD. How to report low-level laser therapy (LLLT)/photomedicine dose and beam parameters in clinical and laboratory studies. Photomed Laser Surg. 2011;29:785–7. https://doi.org/10.1089/pho.2011.9895. 26. Bo K, Frawley HC, Haylen BT, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dys- function. Int Urogynecol J. 2017;28:191–213. https://doi.org/10. 1007/s00192-016-3123-4. 27. Kitchen S. Electrotherapy: evidence-based practice. 11th ed. Toronto: Elsevier; 2001. 28. Nelson RM, Hayes KW, Currier DP. Clinical Electrotherapy. Pearson; 1999. 29. Bellew JW. Clinical electrical stimulation: application and tech- niques. In: Bellew JW, Michlovitz SL, Nolan TP, editors. Michlovitz’s modalities for therapeutic intervention, 6th ed. FA Davis Co.; 2016. p. 287–327. 30. Cameron MH. Physical agents in rehabilitation: from research to practice. Elsevier Health; 2012. 31. Kahn J. Principles and practice of electrotherapy, 4th ed. Churchill Livingstone; 1999. 32. Robinson AJ, Snyder-Mackler L. Clinical electrophysiology: elec- trotherapy and Electrophysiologic testing. 1st ed. Philadelphia: Lippincott Williams & Wilkins; 1995. 33. Low J, Reed A. Electrotherapy explained. Principles and practice. 3rd ed. Oxford: Butterworth-Heinemann; 2000. 34. Belanger A-Y. Therapeutic electrophysical agents: evidence behind practice. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2010. 35. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Associat ion (IUGA)/Internat ional Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010;29:4–20. https://doi.org/10.1002/nau.20798. 36. Messelink B, Benson T, Berghmans B, et al. Standardization of terminology of pelvic floor muscle function and dysfunction: report from the pelvic floor clinical assessment group of the international continence society. Neurourol Urodyn. 2005;24:374–80. https:// doi.org/10.1002/nau.20144. 37. Gormley EA, Lightner DJ, FaradayM, Vasavada SP. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/ SUFU guideline amendment. J Urol. 2015;193:1572–80. https:// doi.org/10.1016/j.juro.2015.01.087. 38. Glinski R, Siegel S. Refractory overactive bladder: beyond oral anticholinergic therapy. Indian J Urol. 2007;23:166. https://doi.org/10.4103/0970-1591.32069. 39. Kuhn A, Keller T, Lawrence M, Morari M. The influence of elec- trode size on selectivity and comfort in transcutaneous electrical stimulation of the forearm. IEEE Trans Neural Syst Rehabil Eng. 2010;18:255–62. https://doi.org/10.1109/TNSRE.2009.2039807. 40. Gracanin F, Trnkoczy A. Optimal stimulus parameters for mini- mum pain in the chronic stimulation of innervated muscle. Arch Phys Med Rehabil. 1975;56:243–9. 41. Alon G. High voltage stimulation. Effects of electrode size on basic excitatory responses. Phys Ther. 1985;65:890–5. 42. Keller T, Kuhn A. Electrodes for transcutaneous (surface) electrical stimulation. J Autom Control. 2008;18:35–45. https://doi.org/10. 2298/JAC0802035K. 43. Gorgey AS, Dudley GA. The role of pulse duration and stimulation duration in maximizing the normalized torque during neuromuscu- lar electrical stimulation. J Orthop Sports Phys Ther. 2008;38:508– 16. https://doi.org/10.2519/jospt.2008.2734. 44. Gorgey AS, Mahoney E, Kendall T, Dudley GA. Effects of neuro- muscular electrical stimulation parameters on specific tension. Eur J Appl Physiol. 2006;97:737–44. https://doi.org/10.1007/s00421- 006-0232-7. 45. Delitto A, Rose SJ. Comparative comfort of three waveforms used in electrically eliciting quadriceps femoris muscle con- tractions. Phys Ther. 1986;66:1704–7. https://doi.org/10. 1093/ptj/66.11.1704. 46. Downey RJ, Bellman MJ, Kawai H, et al. Comparing the in- duced muscle fatigue between asynchronous and synchronous electrical stimulation in able-bodied and spinal cord injured populations. IEEE Trans Neural Syst Rehabil Eng. 2015;23: 964–72. https://doi.org/10.1109/TNSRE.2014.2364735. 47. Fuentes CJ, Armijo-Olivo S, Magee DJ, Gross D. Does amplitude- modulated frequency have a role in the hypoalgesic response of interferential current on pressure pain sensitivity in healthy sub- jects? A randomised crossover study. Physiotherapy. 2010;96:22– 9. https://doi.org/10.1016/j.physio.2009.06.009. 48. Ward AR. Electrical stimulation using kilohertz-frequency alternat- ing current. Phys Ther. 2009;89:181–90. https://doi.org/10.2522/ ptj.20080060. 49. Liebano RE, Waszczuk S, Corrêa JB. The effect of burst- duty-cycle parameters of medium-frequency alternating cur- rent on maximum electrically induced torque of the quadri- ceps Femoris, discomfort, and tolerated current amplitude in professional soccer players. J Orthop Sports Phys Ther. 2013;43:920–6. https://doi.org/10.2519/jospt.2013.4656. 50. Laycock J, Jerwood D. Pelvic floor muscle assessment: the PERFECT scheme. Physiotherapy. 2001;87:631–42. https://doi. org/10.1016/S0031-9406(05)61108-X. 51. Brink CA, Sampselle CM, Wells TJ, et al. A digital test for pelvic muscle strength in older women with urinary incontinence. Nurs Res. 38:196–9. 52. Ortiz OC, Nuñez FC. Dynamic assessment of pelvic floor function inwomen using the intravaginal device test. Int Urogynecol J Pelvic Floor Dysfunct. 1996;7:317–20. https://doi.org/10.1007/ BF01901106. 53. Houghton PE, Nussbaum EL, Hoens AM. ELECTROPHYSICAL AGENTS - contraindications and precautions: an evidence-based ap- proach to clinical decision making in physical therapy. Physiother Can. 2010;62:1–80. https://doi.org/10.3138/ptc.62.5. 54. Dunn PA, Rogers D, Halford K. Transcutaneous electrical nerve stimulation at acupuncture points in the induction of uterine con- tractions. Obstet Gynecol. 1989;73:286–90. 55. Keskin EA, Onur O, Keskin HL, et al. Transcutaneous electrical nerve stimulation improves low back pain during pregnancy. Gynecol Obstet Investig. 2012;74:76–83. https://doi.org/10.1159/ 000337720. 56. Crothers E, Coldron Y, Cook T, et al. Safe use of transcutaneous electrical nerve stimulation for musculoskeletal pain during preg- nancy. J Assoc Chart Physiother Women’s Heal; 2012. 57. Dowswell T, Bedwell C, Lavender T, Neilson JP. Transcutaneous electrical nerve stimulation (TENS) for pain relief in labour. Cochrane Database Syst Rev. 2009. https://doi.org/10.1002/ 14651858.CD007214.pub2. 58. Dowswell T, Bedwell C, Lavender T, Neilson James P. Transcutaneous electrical nerve stimulation (TENS) for pain 1754 Int Urogynecol J (2018) 29:1747–1755 https://doi.org/10.1055/s-0035-1571252 https://doi.org/10.1590/s1677-5538.ibju.2015.0719 https://doi.org/10.1089/pho.2011.9895 https://doi.org/10.1007/s00192-016-3123-4 https://doi.org/10.1007/s00192-016-3123-4 https://doi.org/10.1002/nau.20798 https://doi.org/10.1002/nau.20144 https://doi.org/10.1002/nau.20144 https://doi.org/10.1016/j.juro.2015.01.087 https://doi.org/10.1016/j.juro.2015.01.087 https://doi.org/10.4103/0970-1591.32069 https://doi.org/10.1109/TNSRE.2009.2039807 https://doi.org/10.2298/JAC0802035K https://doi.org/10.2298/JAC0802035K https://doi.org/10.2519/jospt.2008.2734 https://doi.org/10.1007/s00421-006-0232-7 https://doi.org/10.1007/s00421-006-0232-7 https://doi.org/10.1093/ptj/66.11.1704 https://doi.org/10.1093/ptj/66.11.1704 https://doi.org/10.1109/TNSRE.2014.2364735 https://doi.org/10.1016/j.physio.2009.06.009 https://doi.org/10.2522/ptj.20080060 https://doi.org/10.2522/ptj.20080060 https://doi.org/10.2519/jospt.2013.4656 https://doi.org/10.1016/S0031-9406(05)61108-X https://doi.org/10.1016/S0031-9406(05)61108-X https://doi.org/10.1007/BF01901106 https://doi.org/10.1007/BF01901106 https://doi.org/10.3138/ptc.62.5 https://doi.org/10.1159/000337720 https://doi.org/10.1159/000337720 https://doi.org/10.1002/14651858.CD007214.pub2 https://doi.org/10.1002/14651858.CD007214.pub2 management in labour. Cochrane Database Syst Rev. 2009. https:// doi.org/10.1002/14651858.CD007214.pub2. 59. Chao A-S, Chao A, Wang T-Z, et al. Pain relief by applying trans- cutaneous electrical nerve stimulation (TENS) on acupuncture points during the first stage of labor: a randomized double-blind placebo-controlled trial. Pain. 2007. https://doi.org/10.1016/j.pain. 2006.08.016. 60. Tsen LC, Thomas J, Segal S, et al. Transcutaneous electrical nerve stimulation does not augment epidural labor analgesia. J Clin Anesth. 2001. https://doi.org/10.1016/S0952-8180(01)00332-4. 61. Kayman-Kose S, Arioz DT, Toktas H, et al. Transcutaneous elec- trical nerve stimulation (TENS) for pain control after vaginal deliv- ery and cesarean section. J Matern Fetal Neonatal Med. 2014;27: 1572–5. https://doi.org/10.3109/14767058.2013.870549. 62. Dionisi B, Senatori R. Effect of transcutaneous electrical nerve stimulation on the postpartum dyspareunia treatment. J Obstet Gynaecol Res. 2011;37:750–3. https://doi.org/10.1111/j.1447- 0756.2010.01425.x. 63. Machado AFP, Santana EF, Tacani PM, Liebano RE. The effects of transcutaneous electrical nerve stimulation on tissue repair: a liter- ature review. Can J Plast Surg. 2012;20:237–40. 64. Maffiuletti NA. Physiological and methodological consider- ations for the use of neuromuscular electrical stimulation. Eur J Appl Physiol. 2010;110:223–34. https://doi.org/10. 1007/s00421-010-1502-y. 65. Castillo-Lozano R. Effectiveness of neuromuscular electrical stim- ulation in the functional knee rehabilitation in soldiers. Sanid Mil. 2015;71:239–46. Int Urogynecol J (2018) 29:1747–1755 1755 https://doi.org/10.1002/14651858.CD007214.pub2 https://doi.org/10.1002/14651858.CD007214.pub2 https://doi.org/10.1016/j.pain.2006.08.016 https://doi.org/10.1016/j.pain.2006.08.016 https://doi.org/10.1016/S0952-8180(01)00332-4 https://doi.org/10.3109/14767058.2013.870549 https://doi.org/10.1111/j.1447-0756.2010.01425.x https://doi.org/10.1111/j.1447-0756.2010.01425.x https://doi.org/10.1007/s00421-010-1502-y https://doi.org/10.1007/s00421-010-1502-y How to report electrotherapy parameters and procedures for pelvic floor dysfunction Abstract Introduction Methods Results Discussion Conclusions References