In Your Pants with Dr. Susie G - How to get started with TENS for urinary urgency, urinary incontinence, and bladder pain.

Starting point is 00:00:00 You're listening to In Your Pants with Dr. Suzy G, the physiotherapist for your private, helping you get in the know down below. Hey friends, Dr. Suzy G here and welcome to another In Your Pants podcast. One in every three women and one in every 20 men will experience the effects of urinary incontinence. Now those are pretty alarming numbers. The good news is that there's hope and that there's help. So on today's show my guests and I talk about urinary incontinence and urinary urgency and frequency, overactive bladder, and some conservative treatment options that are not talked about in the medical community. We are going to be talking about transcutaneous

Starting point is 00:01:03 tibial nerve stimulation, and my guest is going to help us understand what that treatment option entails and how you can feel empowered to take control of your bladder symptoms today. To formally introduce my guest today, her name is Fiona Rogers. Fiona graduated with her Bachelor of Physiotherapy from the University of Queensland in 1984 and Postgraduate Diploma of Exercise and Sports Science from Sydney University in 1988. She has worked in many settings across the public and private sectors, including the Defense Force and as a clinical supervisor of physiotherapy students. Following the births of her two girls, Fiona had the opportunity to move into pelvic health and has spent the last 25 years working exclusively in the area. For much of that time,

Starting point is 00:02:00 she was a partner in a very large private practice group on the Sunshine Coast, Australia, establishing the Women's Health Service and mentoring all new staff. For the past 10 years, Fiona and her husband have owned the website Pelvic Floor Exercise, Australia's only boutique source of products for pelvic floor rehabilitation, servicing hospitals, private practices, and customers. Through the website, Fiona also provides resources and education for patients and health professionals. In 2019, she developed her first advanced level course for health professionals on neuromodulation for pelvic health, which she has presented around Australia and thanks to COVID

Starting point is 00:02:45 converted to an online format. She has since released a course on transcutaneous tibial nerve stimulation and recently had a scoping review paper published on this topic. Fiona teaches for the APA on their WMPH pathway and is frequently asked to speak on topics of products and neuromodulation for pelvic floor conditions in Australia, overseas, and at medical conferences. This episode is jam-packed with practical information and knowledge to empower you to take control of your bladder concerns. So without further ado, let me introduce Fiona Rogers. I hope you enjoy the show. Hi, Fiona. Thank you so much for being on the show today. Hi, Susie. Thanks so much for having me. Well, I'm so happy to be talking about

Starting point is 00:03:45 this particular unique treatment option that we have for bladder concerns because in the United States alone, it has been said that over 25 million people experience urinary incontinence. That's a lot of people. I'm not sure what the stats are in Australia, but certainly a huge impact on people's lives. I'd love to just talk about that. You know, I think statistically they're similar across the world. Obviously our population is less, but yeah, the stats are very similar. And it's basically a quality of life issue because if you're suffering from urinary urge incontinence which is what we're we're sort of talking about here is you know people become very isolated there's they're worried about leaving home in

Starting point is 00:04:35 case they have an accident and you know I've treated many people over the years who literally have stayed at home and put themselves into you know safe self-isolation which we're all quite used to now having gone through the pandemic but um yeah it's a very very isolating and financially it can be very difficult for people as well because you know the cost of using pads and and treatments and so forth so it's a it's a difficult um condition to to to treat for a lot of people absolutely and not to mention just overall body image and self-esteem when it comes to sexual intimacy of you know dealing with bladder concerns for sure for sure and people will avoid um lots of activities you know like sex and and um exercise uh you know all the sorts

Starting point is 00:05:25 of things that are fun in life people will tend to avoid for fear of having an accident right right exactly and we're here you and i are here having this conversation because there is hope and there's help for urinary incontinence, for bladder urgency and frequency, overactive bladder. And you recently have, with your colleagues, written a paper or published a paper called Transcutaneous Tibial Nerve Stimulation in the Management of Overactive Bladder Scoping Review. So I just wanted to shout out that paper because it's not easy to do research. So kudos to you and your team for putting together this wonderful review. And that's what we're going to be talking about today is what conservative treatment options, particularly the TENS, trans-electrical

Starting point is 00:06:16 nerve stimulation, how that is really not talked about or offered as a treatment option, at least in the traditional medical sense in the medical community. It's not one that's really offered as or known as a treatment option and I don't think that the consumers know how effective this treatment option can be. So Fiona, can you tell us what TENS is and what it isn't and how it might be helpful for things such as urinary incontinence or urgency and frequency? Yeah. Just firstly, can I say it's possibly because a lot of medical professionals aren't aware of it or its efficacy as well and tens has always been left as a last resort but um yeah the research is starting to show us that it should be more one of the first line treatments and

Starting point is 00:07:05 basically it's just using a tens machine with little nerve pulses that um in in very lay terms it um it has a calming effect on on the nerves so we're putting a different input into the nerves to get a different output so it calms the the neural pathways down and we use it for the bladder we can put it along the nerve pathways that affect the bladder and the easiest way to do that is with what we call transcutaneous tibial nerve stimulation so all that big mouthful means is using it through the skin which is transcutaneously and we're putting it over the tibial nerve and the tibial nerve actually sits around that little lumpy bit on the inside of your ankle so it's a nerve that then branches up through the back of the leg and into the sacral area of the spine

Starting point is 00:07:56 and it's one of them and that's one of the nerve pathways that affects the bladder control so and particularly the sensation of the bladder so if we put that different input with the little it's a tingly sensation if anyone has ever used a tensor machine it's actually quite a nice feeling it's a tingly pins and needly type sensation it's going through that nerve to the same pathways that affect the bladder and that can have a very calming effect on the bladder the other way we can use it is putting it across the sacrum so through the tailbone area and will have a similar effect but the research and what we did our paper on is showing us that using it on the ankle is an extremely effective way of helping to calm the bladder down and it's so easy for anybody once

Starting point is 00:08:45 they're shown how to do it to do it at home so you're treating yourself you're not having to go somewhere to to have the treatment it's always part of an overall treatment program so you would be under a health professional guiding you along there but you can take the machine home and and use it yourself at home and there's no side effects which is a great thing because a lot lot of our other treatments for overactive bladder, a lot of the medications do have quite significant side effects. And, you know, the stats show us that a lot of people cease taking those medications because of the side effects. So overall, it does need to be part of a treatment. It's not a standalone treatment, but it can be part of that treatment management program for people at home.

Starting point is 00:09:31 Yeah. And I've personally used it with patients as well, and it has shown to be such an empowering modality for folks to travel with to um help reorganize that neural communication pathway and ultimately not need to use it anymore um for a lot of the cases especially with bladder urgency or even bladder pain which i know we're not predominantly talking about but um i'd love for you fiona to to share what you you know about the use of this particular modality also with with bladder pain? There's less actual research on bladder pain with it, but pain itself, we can use TENS quite successfully for treatment. So it's just applying the principles of using it to the particular area of pain. And likewise, I've had really good success using

Starting point is 00:10:28 TENS for bladder pain, again, as part of the treatment program, but we can certainly use it on the pathways like around the sacrum some people actually get quite good results if we use it over the actually over the bladder at the front and some electrodes on the the lower spine at the back so any form of pelvic pain we have got a lot of research on on pelvic pain to do with you know painful periods etc and as we know we often get bladder pain along with that sort of pain. So, yeah, it can definitely be used very successfully with bladder pain syndrome. Great. And I imagine that a lot of maybe listeners out there are saying, well, how would one, I guess, use it if they wanted to try it? Certainly getting the advice of a

Starting point is 00:11:23 qualified provider and practitioner to dose appropriately because the dosing, I think, is is from what i understand is certainly should be individualized to the patient and and use and guidance and so forth but there are a lot of over-the-counter tens units and i'm not sure if you have favorites or preferences as far as if someone is going to invest in a tens unit you know what does that look like as well so i think that was a mouthful but i just asked you right there i apologize yeah that's okay i think the um it's it's a little bit different because i think over in the states you need to have a script is that correct correct so um my experience here is that yes we can go to um you know website and order one or go to the pharmacy and order one

Starting point is 00:12:08 so whenever i um my suggestion is someone's buying machine is to make sure that it's one that you can actually adjust the parameters on as in changing the hertz or the pulse widths etc because there are a lot of them on the on the market that have a multitude of preset programs and you might think well that's a great machine because it's got you know 15 different programs on it but they're not always appropriate clinically so you are better off getting one that you can adjust and there's some without sort of promoting a particular brand what you would need to you can either get a digital machine like this one which allows you to have really close control of your parameters so you You can change the hertz and the pulse width and also when you're doing your intensity

Starting point is 00:12:58 with the plus and minus buttons here, you're going up in increments of one milliamp whereas a lot of the presets can sort of jump in like increments of five or so which can be a little bit too much. The other type of machine you can get is what we call a digital machine. So these look more like this where you're actually just turning the dials. are always a lot cheaper option, but you're not as quite as accurate with getting your parameters like the hertz and the frequency and the pulse rates on there. But therefore, things like overactive bladder, they're perfectly functional. So, and these are fully adjustable as are some

Starting point is 00:13:38 of the digital machines. So, just checking that you can actually adjust those parameters would be the best option or best advice I could give. Right. No, that's perfect because it should be, as you said dose dependent and just based on that person's clinical um presentations and goals and and so forth because it's going to vary from person to person so a lot of folks will ask you know what's the protocol what's the protocol and they want like a cut and dry answer one size fits all and you know we're here saying it's not that simple because we're embracing our complexity but also the best approach is the individualized approach with under the guidance of a qualified professional there are there are a range of um if you want to call it a protocol of the of to use

Starting point is 00:14:22 for pain or for for overactive bladder but you you need to be able to adjust it within that range yeah and would you feel comfortable to share what that those ranges would be if anyone was interested absolutely for what we generally use for for overactive bladder it's 10 hertz at a 200 pulse width and you take it as high as you comfortably can so what the there should be a strong sensation through the electrodes which if we're doing ttns will be around the ankle and you can check that you're on the tibial nerve by turning it up and if you start to get some toe movement you know that you're on the right nerve pathway or some strong sensation down to the toes you then drop it back a little bit just so it's comfortable so you haven't got you know a toe

Starting point is 00:15:09 cramp happening whilst you're treating and it should be about 30 minutes at a time. And the research goes from once a day to once a week but what the trend now is that if more frequently you do it, the quicker you're going to get a response. So I would always start someone on a daily regime and then cut back down to every second day as things improve and slowly wean off it. pain there's two options you either go very low frequency around the one to four hertz or you go into the high frequency from 80 to 150 hertz two different completely different pathways but we as as far as pain relief goes but generally you will find more effect using the higher range

Starting point is 00:15:59 So something from 80 plus, anywhere from 80 to 150 hertz. So if you trial the different hertz through that range and just see what works best for you. Awesome. Thank you. What a gift to share that information that people are... It's not a protocol. Right, exactly. Right, exactly. Not a protocol, guidelines,

Starting point is 00:16:20 but certainly should be taken into account individually by a case-by-case basis. So Fiona, there's this other... So neuromuscular electrical stimulation, because there's various terms floating around as far as electrical stimulation. So can we clarify for folks like TENS versus neuromuscular electrical stimulation? And when would you use that versus TENS? Okay. It probably should, a better term is neuromodulation to cover the whole lot, but electrical stimulation, probably a better term overall is neuromodulation. So that's what encompasses all of it. And yes, there are

Starting point is 00:17:00 different terms. Electrical stimulation will sometimes cover NMES and TENS. So basically, the difference is TENS is used continuously. So we're either using it as a very low frequency or a high frequency, and it's a constant sensation, and it's aimed at the sensory nerves. So we're trying to either reduce pain or reduce irritation of organs like the bladder. When we're looking at NMES or neuromuscular electrical stimulation, we're aiming at the motor unit. So we're aiming to cause a muscle contraction. And that has to be done with what we call a work rest. So it has to be contracting or working, and then there has to be a rest period to allow the muscle to relax. That is then used in a very specific range, roughly 20 to 50 hertz, because that's the

Starting point is 00:17:49 hertz range that the motor units that cause contraction in muscles will work so we're trying to artificially contract muscle now there may be some people out there who say oh but you can get a contraction above 50 yes you can but clinically we don't use it because it's very uncomfortable and it causes the muscles to fatigue very quickly so ideally we're in that 20 to 50 hertz range and we're aiming to get a muscle contraction. So that would be for someone who has some weakness of a muscle somewhere in the body. When we're talking pelvic health, of course, we're talking the pelvic floor muscles. So we can use NMES to help stimulate muscle contractions of the pelvic floor to help strengthen it. Awesome. Wonderful. Thank you for that very clear definition of what

Starting point is 00:18:41 that is compared to TENS and when someone would and would not use it. Now, in both of those situations, when would these types of treatments be contraindicated or not recommended? Well, there's a whole list of contraindications or precautions, but basically you need to have sensation in the area to be able to use TENS. And, you know, red flags have to have been, And, you know, so I wouldn't recommend that someone without the backing of a health professional and a diagnosis, I wouldn't recommend to go out and actually buy a machine, particularly to be doing pelvic floor muscle strengthening.

Starting point is 00:19:22 Right. But because, you know, there are some conditions, particularly if there's cancer in the area, there's still a precaution and there's a lot of other conditions that would preclude you from using it. So, it should be used under the guidance of a health professional who will make that call for you. Right, exactly. Yes. Thank you so much for that. So, Fiona, in the physiotherapy, physical therapy world, modalities like TENS have been kind of put on the back burner, so to speak.

Starting point is 00:20:04 like we we we are not highlighting those types of modalities because it's like the extreme of that's what we used to do and that's all we did to oh no we're not doing that because there's no effectiveness and intense but the research is showing us especially in neuromodulation with with pain and also what you just described with urinary urgency overactive bladder and incontinence that these modalities do have um some merit and to walk us through kind of you know what you what what needs to happen for us to kind of start to take these modalities back on the table again and have this as a viable treatment option for patients i think i absolutely agree uh the pendulum has swung like i graduated i'm giving away my age here i graduated in 1984

Starting point is 00:20:56 for and we used to use a lot of electrotherapy modalities back then and probably overused back in those days and then the pendulum swung and you know nobody used them at all and I think it's starting to settle where it should be now and in fact that's one of the reasons that I created the courses that I teach because I was constantly being asked how do we use it you know what's the theory behind it because people weren't getting that training anymore and you know the research has improved so much over the years and we've we've seen particularly with neuromodulation um you know with the opioid crisis and uh you know the the research into alternatives has just exploded in recent years and the research is being done in a much better way i guess is

Starting point is 00:21:42 probably the best way to describe it so um it's it's really up to us with the you know with looking at the research and seeing that it works and speaking to our colleagues teaching our colleagues that it can be used it's not the be-all and end-all it's certainly any neuromodulation should be an adjunctive treatment but it's very effective and can be used as a self-management which I think is very empowering to patients as well and it's I find when I speak at medical conferences on the topic, particularly for OAB, a lot of my medical colleagues, you know, the urologists, urogyne's aren't aware that TENS can be used as an alternative. So I see that as one of my roles is to educate. And I always get a great response when I speak on the topic because I thought,

Starting point is 00:22:33 wow, we can give this a try. And then I get contacted and, you know, they asked me how to go about it. Because at the end of the day, we're all, all of us, our patients are in our best interest so we're looking for the best way to to give them alternative treatments right exactly and to that topic of of treatments and expectations you know when people are reinstituting neuromodulation in this way with the electromodalities as far as our expectations of outcomes you know how long should we give something a go before i don't know not not tossing the baby out with the bath water so to speak but saying you know it's not working because i feel like something like this as far as modulating the nervous system is going to take

Starting point is 00:23:24 some time so what has the research shown us as far as expectations around how long should we start to see change that depends what modality and what you're treating so but definitely if If you were looking at muscle strength, you really need to give it a good sort of 16 weeks, 12 to 16 weeks going by the research, which is what you would be doing if you were doing muscle training anyway. When we're looking at things like overactive bladder, what we found when we did our review is that you should expect some result within a couple of weeks. Like a patient should be starting to notice that perhaps their episodes are less intense or less frequent. but that you really need to give them a full sort of 12 weeks of treatment to to be seeing a decent effect but most people will start to see an effect within that couple of weeks and where we're heading now with the research seems to be that yes more frequently uh will give you a quicker result

Starting point is 00:24:26 so you know trying it every day for example so it it's not that long and it's it's um it's certainly worth trying these techniques to see if we get an effect but just on that point an outcome measure is really important because it's to track how you're going it's very easy to hand a machine to a patient and say see you in four weeks and they will still have symptoms probably in that four weeks so if you say have you improved oh no I've still got you know I'm still got some urgency but they need something to compare to from the start so if they've had a done a bladder diary or used an outcome measure of some sort, we can then look back and go, oh, but look, the trend is, you know, over each week

Starting point is 00:25:09 you've reduced the number of episodes or the intensity of that frequency. So I think that's an important point to make. We do need to track these changes so that the patient themselves can actually see, yes, there's been an improvement. It's easy yourself if you've been in pain, for example, for a while and it's very hard to look back and go, oh, is it different than it was a month ago when you still got pain now so I think those outcome measures are very

Starting point is 00:25:37 important a very good point that you're bringing up you know that those tracking that progress is so helpful for people to stay motivated with the treatment too you know both patient and clinician to say you know what we're doing is actually making steps in the in the positive direction and that it is making change and and to stick with it you know it gives you the gumption to stick with a process because often we you know if we're dealing with something and we're in the storm it's very hard to see something even those small changes that might be happening it's just not as obvious to us because we are the person experiencing it right so i think having some i would say evidence objective evidence where you're logging the bladder diary for example

Starting point is 00:26:25 is something very easy to do for for patients to just log their their symptoms start of treatment and and notice that and so for the clinician as well and then those formal outcomes measure outcome measures that you were mentioning so so empowering again to put treatment in the hands of the of the patient really under guidance but really empowering them to um to see their successes and also understanding why they're doing the treatment is so important to explain this is what we're expecting this is what we need to do and to understand what what to expect right exactly exactly so if someone was to want us to attempt to try this type of therapy for OAB overactive bladder or urinary urgency frequency or bladder pain and let's say they

Starting point is 00:27:18 don't know kind of where to start what would you recommend as far what advice would you give them if they're really interested in trying this um who would they go to first where would they seek consult um certainly we're physiotherapists so i'm biased um pelvic therapist but definitely yeah look we'll certainly here in australia where we're first point of contact so you know just going and seeing the local um pelvic floor or continence physio would be helpful um it really does depend to and then they if the the problem appears to be something more significant they can then refer on to uh the the gp and medical team urologist etc so i imagine over in the states what your referral system would be to see your um primary provider

Starting point is 00:28:09 first and even to you know say that you've heard that this might work um it would it be an option for me because sometimes your medical providers may not be fully aware of this particular method of treatment. Exactly, exactly. In the states, it depends on which state you live in, whether you have direct access to a physio like in Australia. So in my state, North Carolina, we are a direct access state, which means we are primary care, first care providers. so but different states are not that way yet um so and as you're saying i think the biggest barrier is that primary care providers are not aware of this as a first line of treatment or even um urogynecological or urological care or medical providers are not aware that this can be

Starting point is 00:29:02 a very viable treatment. So definitely connecting with a pelvic therapy provider who can guide and make referrals or connect with your doctor even to recommend such a treatment option. So yeah, I just encourage everyone not to let that be a barrier and really to just speak up to be an advocate for your own self as a as a patient as a person um as a consumer as a as a knowledgeable consumer um and bringing these topics up to your providers to spread the word about other treatment options that are available other than medications or or surgical interventions absolutely and that that was one of the primary reasons we we wrote the paper because um you know that the other like side effects of medications and you know the more invasive treatments that we can go on to

Starting point is 00:30:00 at least if we've tried you know lifestyle behavioral is always first line and that's why it's good to connect with a provider who can like a physical therapist or physio who can teach you all of that but adding in the tens at that point if it doesn't work it's not going to work for everybody but it works for a lot of people but if it doesn't work you've then still got those other options the more invasive ones up the sleeve to move on to rather than trying and failing with those and coming back to to try something that's a little quite simple right and i can imagine doing the backwards maneuver might be posed for more challenges with with these types of modalities or conservative treatment after the fact not that it's impossible but i imagine i'm not sure what

Starting point is 00:30:43 your experience is i'm not entirely sure what that looks like that path might look like if we went down that route of surgical intervention and then then tried the more conservative um simple yeah it's more that they'll try things like medication and so forth but interestingly pretty much all of the research has been done on refractory oab so they've tried things like medication so that oh let's let's use that patient cohort to do the research on so i'm really hanging for somebody to do it as a first line treatment because we're still getting excellent results on refractory oab so um you know my big thing is would they be refractory if we had tried the tens before we got to that point so um that's what excites me if we're going to sort of head down that pathway

Starting point is 00:31:30 and anecdotally absolutely it does work um and prevent people from you know getting to that very chronic stage oh well that's just so that's so helpful i'm i had no idea that most of that research is just on refractory overactive bladder that that's yes what a good point you bring like what would the outcome be if we just started this sooner than later and kept it simple and can i just say there too um the alternative is what we call percutaneous nerve stimulation so it's doing the same thing but instead of electrodes on the surface of the skin it's a needle that's put into right through the skin to sit next to the tibial nerve that has to be done by a medical team it's done by the urologist urogynese etc it's invasive you go once a week

Starting point is 00:32:18 for 12 weeks it is very effective but you have to go through that whole process and it's expensive as well so what they're seeing now is that we've they've been quite a few studies that have shown there's equal efficacy of doing it through the skin or with a needle so again if we can you know treat a lot of people with it transcutaneously they can do it themselves at home then if that doesn't work they they've then got that option to move on to ptns so if you're listening and you go to provide myself we'll just do ptns um that's fine if that's the option that you choose but there is the option of doing it yourself at home which is less side effects cheaper easier for you to do and you can use it as ongoing maintenance so that's that's just a slight

Starting point is 00:33:04 um you know another option there but just to be aware of the differences uh thank you for that clarification i that is so important because you're right um access to care uh effective equally effective and can be done at home less time needed to go to doctors um etc so wow again so empowering very hopeful uh i feel like all roads all roads lead to a pelvic therapist because we're the ones that are i hate to say it but we're the ones that are not biased at all not at all um but but see really i mean we are primary educators in in in the this field and um yes you know you may go to a medical provider a doctor but that they they they are not aware, as you're saying, that's the biggest challenge is they're just not aware that these

Starting point is 00:34:00 other options are as effective and just as viable and hold merit than some of these other invasive and more costly and time-consuming options. And also nine times out of 10, certainly here, if someone goes via their GP or the urologist or urogyne, they refer them to us as a start anyway before they do go on to the more invasive ones so that's my experience you know in my little part of the world here yeah yeah i i have mixed reviews about that here in the states i i still hear that there is a lack of yes here's the first line of treatment see a pelvic therapy i'm hearing that more often but still not as much as it is it i think it should be yeah unfortunately especially with pain uh it's sadly it's still several years is the stat before people actually

Starting point is 00:34:54 get access to to providers like ourselves um for for pain care uh for pelvic pain so yes we're working on it one patient at a time and by just doing this episode i think is very empowering and educating consumers and people about their options and um sharing that sharing that with health professionals and their friends and family and colleagues so thank you so much fiona i really appreciate you sharing your knowledge and your wisdom uh on the topic any new ventures up your horizon adventures professionally uh or personally personally i'm about to sell my we're selling our house and downsizing our children have moved out professionally I've got a couple more courses that are under production at the moment for

Starting point is 00:35:50 health professionals so yes and we've always expanding our website which includes your book now we have Susie's book here down under on our website so thank you very excited about that so yes and I'm just looking forward to hopefully the world getting back to a little bit normality and and uh being able to go to conferences and run courses face to face again and you know you know being with people yeah i agree i agree fiona and thank you um for that humble shout out for the book can you tell the listeners and the viewers out there the name of your website and maybe yours if you're on i think you are on social media as well on instagram at least that's where i'm at Yeah, so the website is pelvicfloorexercise.com.au

Starting point is 00:36:39 and we're based in, as you can tell by my accent, Australia. I have my Facebook is Pelvic Floor Exercise and my Instagram is Pelvic Floor Exercise. So it's all pretty much the same thing there. Yeah, so we sell products to the general public and health professionals to do with pelvic floor rehab. Awesome. and the courses for clarification are for health professionals is that correct yes my yeah my

Starting point is 00:37:07 courses are for health professionals yeah okay wonderful wonderful and any sneak any teaser about what what's brewing do you want to throw out a teaser for us i'm very curious but no pressure no that's okay i've uh this is for uh vaginal weights is my next one so the draft is done i've just got to um have some dedicated time to start recording it uh so that'll be another sort of standalone short course on the clinical use of vaginal weights awesome i'm excited about because there's some great research that seems to have been ignored from the sort of the 80s and the 90s yeah it's very interesting i love it i love it that you're bringing back these oldies but goodies you know i should i say that like the the research the the the the modalities that we

Starting point is 00:37:57 have been here for a very long time and have sort of kind of again been put on the back burner but now that we're understanding more about how they're being used and and have better research as you say that they're showing to be more promising than we once thought they were so but it's understanding my big thing is it's understanding how to use it properly right so i get asked all the time what's the protocol for strengthening the pelvic floor but if you understand the principles of neuromodulation, then you can work that out and adjust it for the individual. And to me, that's crucial. Yes. Yes. Well said. Great points. Thank you so much, Fiona. Again, really appreciate your time being here today. And I look forward to connecting you

Starting point is 00:38:44 with the rest of the world and all of the links that you've shared. Your website, we'll definitely be putting that in the show notes for folks and in the description on YouTube. So please check that out. Yeah. So thank you again, Fiona. Really appreciate it. And for all of our listeners out there and viewers, thank you so much in loving wellness for your pelvis. This is Dr. Susie. Until next time. Thanks for listening to today's episode. Be sure to head on over to drsusieg.com where you can get more information, show notes, and related articles on today's topic. Also, if you like what you're hearing, head on over to iTunes, subscribe to the podcast, and leave us a rating and review. We'd love to hear your feedback. Thanks again.

In Your Pants with Dr. Susie G - How to get started with TENS for urinary urgency, urinary incontinence, and bladder pain.

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