1. No category

Use of High Voltage Pulsed Galvanic Stimulation for
Patients with Levator Ani Syndrome
Lydia Morris and Roberta A Newton
PHYS THER. 1987; 67:1522-1525.
The online version of this article, along with updated information and services, can
be found online at: http://ptjournal.apta.org/content/67/10/1522
Collections
This article, along with others on similar topics, appears
in the following collection(s):
Electrotherapy
Other Diseases or Conditions
e-Letters
To submit an e-Letter on this article, click here or click on
"Submit a response" in the right-hand menu under
"Responses" in the online version of this article.
E-mail alerts
Sign up here to receive free e-mail alerts
Correction
A correction has been published for this article. The
correction has been appended to this PDF. The
correction is also available online at:
http://ptjournal.apta.org/content/68/2/265.full.pdf
Downloaded from http://ptjournal.apta.org/ by guest on September 9, 2014
Use of High Voltage Pulsed Galvanic Stimulation for
Patients with Levator Ani Syndrome
LYDIA MORRIS
and ROBERTA A. NEWTON
Levator ani syndrome is characterized by brief, intermittent pain and discomfort
in the perirectal or rectal region that can be aggravated by sitting. Physical
therapists are beginning to receive referrals for pain reduction in this patient
population. The purpose of the study was to examine the use of high voltage
pulsed galvanic stimulation (HVPGS) for reducing symptoms in patients with
levator ani syndrome. A descriptive research design was used. Treatment consisted of one hour of HVPGS at a frequency of 120 Hz and at an intensity to the
patient's maximum tolerance applied through a rectal probe. Results on 28
patients indicate that 50% had pain or symptom relief, or both, after an average
of eight treatments. Those patients who were unresponsive to treatment had a
primary diagnosis of irritable colon or were postsurgical. We are continuing to
examine this treatment and will conduct follow-up examinations on those patients
who obtained pain relief. Based on these preliminary results, we believe that
HVPGS is an effective treatment for selected patients in this population.
Key Words: Electric stimulation, Pain, Physical therapy, Rectum.
The purposes of this article are 1) to present an electrotherapeutic method for treating patients with levator ani
syndrome and 2) to discuss the preliminary results of this
treatment on 28 patients with a diagnosis of levator ani
syndrome.
The levator ani muscle is a major component of the pelvic
floor musculature. This muscle is composed of three parts:
the pubococcygeus, the iliococcygeus, and the puborectalis
(Fig. 1). The levator muscles are innervated by the fourth
sacral nerve.1
The cause of levator ani syndrome often is unknown, but
it may accompany other conditions (eg, anorectal infection
or surgery or trauma). Thiele noted that the syndrome's most
common cause was anal infection.2 He believed the proximity
of the lymphatic drainage to the pelvic musculature was
responsible for myositis or reflex spasm of the levator ani
muscle.2,3 He also reported associated spasm of the piriformis
muscle in 43.7% of the 324 patients he examined.
A common physical finding is tenderness on palpation of
the left levator muscles.1"4 Symptoms include intermittent
pain or discomfort in the perirectal region. Pain is believed to
be referred from spasm of the levator ani muscle, lasting
several seconds to several hours.4 Most often the patient
complains of pressure and pain within the rectum that may
be severe, sharp, aching, or burning. Sitting may increase the
symptoms, and the patient may awake at night from the pain.
Generally, the pain is unrelated to bowel function; however,
defecation may exacerbate the pain. Often symptoms may
Ms. Morris is Chief, Department of Physical Therapy, Retreat Hospital, 2621
Grove Ave, Richmond, VA 23220.
Dr. Newton is Associate Professor, Department of Physical Therapy, PO Box
224, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA 23298-0001 (USA).
Address all correspondence to Dr. Newton.
This article was submitted May 5, 1986; was with the authors for revision 20
weeks; and was accepted February 2, 1987. Potential Conflict of Interest: 4.
occur in those individuals who sit for long periods of time on
the toilet, straining or reading.5
Treatment for levator ani syndrome has included sedatives
or muscle relaxants,2 levator muscle massage,2 exercises,5 and
most recently high voltage pulsed galvanic stimulation
(HVPGS).4,6,7 Grant and colleagues treated 316 cases of levator ani syndrome with massage, heat, and diazepam.1 Sixtyeight percent of the patients had relief of symptoms after three
or fewer massage treatments. Thiele reported similar results.
Of 223 patients with levator ani syndrome whom he treated
with massage, 63.7% were cured; that is, they reported no
pain or other symptoms upon follow-up for at least 10 years.2
Corman considered massage a contraindication and advocated the use of perineal strengthening exercises.5 Only empirical evidence was provided for his exercise program. Those
individuals who were considered neurotic did not benefit from
the exercise program. Corman reported that self-hypnosis had
been of benefit to some patients; however, no substantiating
evidence was provided.
Most recently, HVPGS has been used as a treatment for
levator ani syndrome. Sohn et al published the first article on
this form of treatment in 1982.4 In that study, 80 patients, 60
women and 20 men, were treated with HVPGS. The patients
were positioned in the left lateral Sims' position. A specially
designed metal rectal probe through which an electrical stimulus of negative polarity, a frequency of 80 Hz, and sufficient
voltage to produce the most tolerable but comfortable sensation was delivered. No rationale for the selection of the
electrical stimulation characteristics was given. The patients
received a minimum of three one-hour treatments within a
3- to 10-day period. Sixty-nine percent of the patients had
excellent results, that is, complete reduction of pain and no
recurrence during follow-up. Twenty-one percent of the patients had good results, that is, complete reduction of pain
but with recurrence during follow-up. The remaining 10% of
PHYSICAL THERAPY
1522
Downloaded from http://ptjournal.apta.org/ by guest on September 9, 2014
RESEARCH
Fig. 1. Anatomy of the levator ani muscle.
the patients, including six patients whose symptoms were
believed to be of neurologic origin, did not respond successfully to the electrical stimulation treatment. Sohn et al considered the treatment to be successful because 90% of the
patients obtained good or excellent results.
Nicosia and Abcarian treated 45 patients with levator ani
syndrome.6 The electrical stimulation characteristics and
treatment procedures were the same as those described in the
study by Sohn et al4; however, treatment time was 15 to 30
minutes given every other day for one to nine treatments.
The average number of treatments was five. Total relief of
pain occurred in 80% of the patients. Five patients had pain
relief followed by recurrences that responded successfully to
additional treatment. The remaining four patients had some
or no pain relief. Because of the success of the treatment,
Nicosia and Abcarian concluded that HVPGS was the preferred treatment for levator ani syndrome. They further concluded that electrical stimulation also could serve as a test for
levator ani syndrome because most patients with this condition had considerable pain relief after the first treatment.
Oliver and colleagues also used HVPGS to treat 102 patients
diagnosed with levator ani syndrome.7 All treatments were 60
minutes in duration, and a total of three treatments were
given in a 10-day period. Forty-three percent of the patients
had good results, 25% had moderate improvement, and 32%
had poor responses. Of the 33 patients with poor responses,
21 continued to have recurrent symptoms, and 12 subsequently were found to have diagnoses other than levator ani
syndrome.
Several specialists in colorectal surgery at Retreat Hospital
who had read the articles cited previously began to refer
patients to physical therapy. Because this is a new population
of patients available to physical therapy, we decided to study
the effectiveness of HVPGS for treating these patients. We
used a descriptive research design to determine whether
HVPGS can reduce symptoms in patients with levator ani
syndrome.
METHOD
Subjects
Twenty-eight patients with a diagnosis of levator ani syndrome were referred to physical therapy for treatment with
HVPGS. Twenty-three of these patients were women, and 5
were men. Their age range was 40 to 92 years, with a mean
age of 62.9 years. Seventy-nine percent of the patients had a
primary diagnosis of levator ani syndrome. Twenty-one percent had other primary diagnoses, such as irritable colon,
incontinence, or rectocele; however, all had secondary diagnoses of levator ani syndrome. Twenty-five percent of the
patients had undergone rectal surgery in the last 15 years.
Many patients described their symptoms as a pressure or
burning sensation in the rectum of short duration. Thirty
percent of the patients perceived the pressure as incomplete
emptying of the bowels. Their symptoms were aggravated by
sitting for prolonged periods, especially when riding in a car.
Twenty-five percent stated that their symptoms were aggravated by standing. All except four patients reported intermittent occurrence of symptoms.
Evaluation
Those patients who agreed to participate in the study signed
an informed consent statement. We evaluated each patient
initially by recording a history of the present problem and
asking the patient to describe its symptoms. We then gave the
patient standard instructions for completing two visual analog
scales (VASs) for pain, one designed to measure the intensity
of the discomfort and one to indicate the unpleasantness of
Volume 67 / Number 10, October 1987
Downloaded from http://ptjournal.apta.org/ by guest on September 9, 2014
1523
the discomfort (Fig. 2). The left end of the 15-cm VAS for
intensity of discomfort was labeled "no sensation," and the
right end was labeled "the most intense sensation imaginable."
The left end of the 15-cm VAS for unpleasantness of the
discomfort was labeled "not bad at all," and the right end was
labeled "the most intense bad feeling possible for me." The
patient placed a mark on the line of each VAS to indicate the
perceived level of pain intensity or discomfort. The reliability
and validity for using two pain scales has been documented
previously.8 The patients completed the VASs and described
their symptoms before treatment on the first day of the study
and after treatment on the fourth and last days of the study.
INTENSITY
THE MOST INTENSE
SENSATION IMAGINABLE
NO SENSATION
UNPLEASANTNESS
Treatment
The patient was positioned in the left lateral decubitus
position. Surgilube,* a sterile and bacteriostatic surgical lubricant, was placed around the anal opening. A commercially
available sterile metal probe (Fig. 3) was inserted rectally and
held securely with a strap. The dispersive pad (20.3 x 25.5
cm) was placed over the right hip and secured with a strap.
The electrical stimulation characteristics on a high voltage
pulsed galvanic stimulator† were set at a frequency of 120 Hz
and negative polarity. The twin peak waveform and pulse
duration are fixed in the machine. The intensity initially was
increased to patient tolerance. The patient was instructed to
increase the intensity gradually to tolerance throughout the
treatment, and the maximum intensity was recorded at the
end of each session. Intensities ranged from 100 to 400 V
with a mean treatment intensity of 294 V. Each treatment
session was 60 minutes in duration. Patients were treated two
times a week.
The probe was sterilized by the following procedure. After
removal, the probe initially was cleaned with green soap,
dismantled, and placed in an automatic endoscopic cleaner*
for 20 minutes using Cidex* as the sterilizing agent.
Data Analysis
Pain relief was recorded by two methods. A nominal scale
for subjective responses was used. After treatment, the patient
was asked whether the symptoms had been relieved. Perceived
pain intensity and discomfort values were obtained by measuring from the left end of the VAS to the patient's slash mark.
Values were recorded in centimeters. Because this patient
population typically has intermittent pain, many times the
patient had difficulty deciding where to mark the scale. Based
on this observation, we did not calculate a group mean.
Instead, we used a nominal form of measurement to score
the VAS; that is, pain relief occurred if the posttreatment
value was 0 cm, and all other values indicated no pain
reduction.
RESULTS
The number of treatments given ranged from 3 to 10.
Twenty-five percent of the patients had pain or symptom
relief, or both, after four treatments. Fifty percent of the
patients had pain or symptom relief, or both, after an average
of 7.5 treatments. Of the 7 patients (25%) who were unresponsive to treatment, 2 had diagnoses of irritable colon, 3
* Surgikos and Arbrook, Inc, 2500 Arbrook Blvd, Arlington, TX 76014.
† EGS Model 300, Electro-Med Health Industries, Inc, 6240 NE 4th Ct,
Miami, FL 33138.
‡ American Endoscopy, 9350 Progress Pkwy, Mintor, OH 44060.
NOT BAD AT ALL
THE MOST INTENSE
BAD FEEUNG
POSSIBLE FOR ME
Fig. 2. Visual analog scales to measure intensity and unpleasantness of pain.
Fig. 3. Rectal probe. Left end of the probe is composed of the
plastic handle with a connector to fit into the electrode lead. The right
end is the stainless steel portion of the electrode that conducts the
electric current.
had previous surgeries (1 was a 92-year-old one month
posthemorrhoidectomy), 1 had abdominal pain, and 1 had
psychiatric problems. In total, 75% of our patients received
complete or partial pain or symptom relief with HVPGS
treatment.
DISCUSSION
Examination of the results of our study revealed that 25%
of the patients had pain or symptom relief, or both, after four
treatments, and the percentage of patients obtaining pain or
symptom relief doubled after an average of 7.5 treatments.
Sohn and colleagues4 reported complete pain relief in 69% of
their patients after three treatments, and Nicosia and
Abcarian6 reported an 80% success rate after an average of
five treatments. One possible explanation for our slightly
lower initial success rate was our patient sample. About 50%
of the patients we treated were those who, as a last resort, had
been referred to specialists in colorectal surgery to obtain
relief of their symptoms. Although the greatest percentage of
patients had primary diagnoses of levator ani syndrome, 21 %
had other primary diagnoses and did not respond well to
electrotherapeutic treatment. Oliver et al also noted that
patients who were classified as having levator ani syndrome,
but had other primary diagnoses, did not improve.7 Sohn et
al also reported that six patients who did not respond to
treatment were believed to have levator ani syndrome of
neurologic origin.4
The treatment rationale presented by Sohn and colleagues
for the relief of levator ani spasm is based on the postulate
that electrical stimulation probably produces a sustained con-
1524
PHYSICAL THERAPY
Downloaded from http://ptjournal.apta.org/ by guest on September 9, 2014
RESEARCH
traction of the levator muscle. With time, the muscle fatigues
and the spasm cycle is broken.4 Although this is one method
to interrupt a pain-spasm cycle, we would not ignore the
possibility of blocking pain perception via local, segmental,
or central means.
The electrical stimulation characteristics chosen for our
study were based on those of previous studies using
electrotherapy4,6,7 and our pilot study. For the pilot study, we
used a 20-minute treatment time, which was the average
treatment time reported by Nicosia and Abcarian.6 Although
Nicosia and Abcarian obtained good results using a short
treatment time, that was not evidenced in our pilot study. We
increased the treatment time to one hour, the treatment time
used by both Sohn et al4 and Oliver et al.7 We increased the
frequency to 120 Hz as compared with the frequency of 80
Hz used by Sohn et al4 and Nicosia and Abcarian.6 The
electrical generator used by these researchers had a maximum
frequency of 80 Hz. Our decision to increase the frequency
was based on research supporting high frequency electrical
stimulation for relief of chronic pain.9
A very important finding of our study was that the VASs
we used for this patient population were not suitable to
measure the intensity and discomfort of their pain. These
patients typically have intermittent pain and may not be able
to remember accurately their pain intensity and discomfort.
We, therefore, would not recommend the use of the VAS in
future studies, but rather the use of word choices to describe
perceived levels of pain and discomfort. In a follow-up study
currently in progress, we are using word choices and have
selected those words often reported in the literature for levator
ani syndrome. This study is based on a two-group research
design, one group receiving HVPGS only and the other group
receiving HVPGS and performing the pelvic exercise used by
Corman.5
In summary, to successfully manage this patient population
we agree with Nicosia and Abcarian that a complete explanation of the procedure, what is expected as an outcome, and
continued dialogue with the physician are of utmost importance.6 Because HVPGS treatment is a relatively new treatment for pain relief for levator ani syndrome, periodic followup of the patients is an important consideration.
CONCLUSION
We concur with the previous studies that HVPGS is effective in those patients with levator ani syndrome. We also
conclude that patients with other primary diagnoses do not
respond as well to this treatment. Lastly, we determined that
the VAS was not an appropriate measure for assessing intermittent pain in this patient population.
REFERENCES
1. Grant SR, Salvati EP, Rubin RJ: Levator syndrome: An analysis of 316
cases. Dis Colon Rectum 18:161-163, 1975
2. Thiele GH: Coccygodynia: Cause and treatment. Dis Colon Rectum 6:422436,1963
3. Thiele GH: Tonic spasm of the levator ani, coccygeus and piriformis
muscles. Transactions of the American Proctologic Society 37:145-155,
1936
4. Sohn N, Weinstein MA, Robbins RD: The levator syndrome and its treatment with high voltage electrogalvanic stimulation. Am J Surg 144:580582, 1982
5. Corman ML: Colon and Rectal Surgery. Philadelphia, PA, J B Lippincott
Co, 1984, pp 733-734
6. Nicosia JF, Abcarian H: Levator syndrome: A treatment that works. Dis
Colon Rectum 28:406-408, 1985
7. Oliver GC, Rubin RJ, Salvati EP, et al: Electrogalvanic stimulation in the
treatment of levator syndrome. Dis Colon Rectum 28:662-663, 1985
8. Price DD, McGrath PA, Raffi A, et al: The validation of visual analogue
scales as ratio scale measures for chronic and experimental pain. Pain
17:45-56,1983
9. Meyerson BA: Electrostimulation procedures: Effects, presumed rationale,
and possible mechanisms. In Bonica JJ, et al (eds): Advances in Pain
Research and Therapy. New York, NY, Raven Press, 1983, vol 5, pp 4 9 5 534
Volume 67 / Number 10, October 1987
Downloaded from http://ptjournal.apta.org/ by guest on September 9, 2014
1525
Use of High Voltage Pulsed Galvanic Stimulation for
Patients with Levator Ani Syndrome
Lydia Morris and Roberta A Newton
PHYS THER. 1987; 67:1522-1525.
This article has been cited by 1 HighWire-hosted articles:
Cited by
http://ptjournal.apta.org/content/67/10/1522#otherarticles
http://ptjournal.apta.org/subscriptions/
Subscription
Information
Permissions and Reprints http://ptjournal.apta.org/site/misc/terms.xhtml
Information for Authors
http://ptjournal.apta.org/site/misc/ifora.xhtml
Downloaded from http://ptjournal.apta.org/ by guest on September 9, 2014
Errata
On page 1524 of the article "Use
of High Voltage Pulsed Galvanic
Stimulation for Patients with Levator
Ani
Syndrome" (PHYSICAL THER-
APY, October 1987), the EGS 300 was
cited in the footnote as the stimulator
used in the study. This is incorrect.
The correct model number is EGS
100-2. The EGS 300 is a batteryoperated, portable model. The authors regret the error.
Please note a correction in the
Membership Qualifications Prescribed By The Board ofDirectors, as
published in the October 1987 issue
of PHYSICAL THERAPY, page 1619.
Under "A. Active Membership,"
number 4 should read as follows:
4. If trained outside the United
States, United States citizenship, a
legal permit for permanent
residence in the United States, or
a legal permit to work in the
United States, and graduation
from an education program(s)
that by credentials evaluation is
(are) determined to be equivalent,
with respect to professional
education, to entry-level physical
therapist education in the United
States.
Subject-matter Experts, I urge openmindedness toward the methods used
by authors. As Feinstein has stated,
The investigator, because of problems
in feasibility or mensuration, may not
be able to acquire the exact data that
would be most desirable. When the
investigator uses various types of substitution, the reviewer may not agree
that the substitutes were satisfactory.
The investigator, attempting to work
with the world's imperfections may
seek the enlightenment of a candle in
darkness; the reviewer may be discontent with anything other than a mercury-arc beam.
REFERENCES
1. Vandenbroucke JP: A check list for observational research? J Chronic Dis 40:1067-1068,
1987
2. Weiss CH, Bucuvalas MJ: Truth tests and utility
tests: Decision makers' frames of reference for
social science research. American Sociological
Review 45:302-313,1980
3. Lewin K, quoted in Argyris C, Putnam R, Smith
DM: Action Science. San Francisco, CA, Jossey-Bass Inc, Publishers, 1985, p 1
4. Feinstein AR: Clinical Epidemiology. The Architecture of Clinical Research. Philadelphia, PA,
W B Saunders Co, 1985, pp 34-35
By tolerating deviance from personal
views or present norms, those involved
in the review process may extend the
value of their present service to the
profession. Even if, as a result, a work is
published that is questionable, at least it
will be out in the open to be questioned.
RICHARD W. BOHANNON
Associate Professor
School ofAllied Health Professions
University of Connecticut
Box U-101
358 Mansfield Rd
Storrs, CT 06268
In the article "Relief of Low Back
Pain by Epidural Injection," by Russell Woodman (PHYSICAL THERAPY,
November 1987), we stated incorrectly that the epidural injection was
performed by a physical therapist.
The injection was performed by an
orthopedic surgeon, Dr. Richard
Froeb. We regret the error.
Please note the following changes
to the article "Muscle Pressure Effects on Motoneuron Excitability: A
Special Communication" (PHYSICAL
THERAPY, November 1987):
1. On page 1720, the sentence
"At least three trials of most
subjects, however, were significantly different" is incorrect.
The sentence should be
changed to "At least three
trials of most subjects, however, were not significantly different." We regret the error.
2. On page 1721, the sentence
"As shown in the Figure (illustration A), a mean M-wave
depression to 35% of the controls also was observed on
pressure application" should
be corrected to read "As
shown in the Figure (illustration A), a 35% mean M-wave
depression was also observed
upon pressure application."
Volume 68 / Number 2, February 1988
265