In this original study, the treatment of multiple sclerosis (MS) with non-invasive neuromodulation is explored. MS is an autoimmune inflammatory disease that causes damage to myelin. This damage weakens the ability of nerves to conduct electrical impulses, resulting in various autonomic symptoms such as spasticity, fatigue, neuropathic pain, and urinary incontinence. These factors directly affect the patient's quality of life, which worsens during a flare-up of the disease.
In this study, we explore NESA non-invasive neuromodulation, since it can regulate the autonomic nervous system. It is a non-invasive and painless electrotherapy that uses low-frequency microcurrents. Previous studies suggest that normalising the functions of the autonomic nervous system can alleviate various of the symptoms that the people with MS have to suffer, including incontinence, chronic pain or lack of sleep. Pain-focused neuromodulation is expected to be most effective in patients with chronic diseases, however, its effectiveness in patients with various MS disease-based conditions needs to be tested (1, 2, 3).
The objective of this study is to enhance the management of urinary incontinence resulting from neurogenic bladder and alleviate pain in patients with multiple sclerosis. Additionally, we aim to enhance their overall quality of life.

This is a preliminary quasi-experimental study that invited 11 patients from a local multiple sclerosis association to participate. Since this is a pilot study, sample size calculations were not necessary. All patients provided informed consent and the corresponding clinical research ethics committee approved the study. The treatment lasted for three weeks with 15 sessions, one per each working day. The sample was randomly divided into two groups:
- Group A. The NESA treatment programmation used in this group consisted of programme 2 and 3 (with directional electrode at L1-L3) and programme 5 and 7 (with directional electrode at C7), each lasting for 15 minutes.
- Group B. In this case, this group went under the NESA treatment programmation consisting in programme 2, programme 5, programme 6, and programme 7 (with the directional electrode located at C7), also with 15 minutes per programme.
Measurements were collected prior treatment, at session 7, and after session 15 using the following questionnaires:
- Bladder Control Self-Assessment Questionnaire (B-SAQ)
- Urinary Incontinence Questionnaire (ICIQ-SF)
- Pittsburgh Sleep Quality Questionnaire (PSQQ)
- Visual Analogue Pain Scale (VAS).
The differences between the baseline and final assessment records were analysed using Friedman's test with a 95% confidence interval. Furthermore, non-parametric tests such as the Mann-Whitney test were used to analyse the differences between the combinations of both programmes.

Evaluation by week
Significant differences in sleep quality were found between weeks in both group A (p=0.019) and group B (p=0.030). The Pittsburgh questionnaire scores improved in all patients over the three-week treatment period.  
In terms of incontinence evaluation, significant differences were also found in group A for the B-SAQ test in symptoms (p=0.008) and incontinence (p=0.046), with positive improvement observed over the three weeks of treatment. Furthermore, the results of the ICIQ_SF test showed significant differences between weeks only in group A (p=0.13), while no significant differences were found in group B regarding incontinence assessment. 
Additionally, significant differences in pain assessment were observed only in group A (p=0.022), with lower levels reported at the end of treatment.

Comparison between groups
The study analysed the differences between the start and end of treatment groups to determine the effectiveness of each protocol. Significant differences were found in sleep quality between the groups (p=0.024), with group A showing greater improvement.

This initial study on non-invasive neuromodulation NESA for MS symptomatology has demonstrated the effectiveness of this treatment in improving neurogenic bladder-related urinary incontinence. Additionally, the study has shown an improvement in the quality of sleep, which is typically poor and fragmented in these patients. Finally, a reduction in pain perception has been observed. The research results demonstrate the effectiveness of NESA microcurrents, particularly when using the combination of programmes in group A. This approach was more effective in treating all studied symptoms, including incontinence, pain, and sleep.

This new technology aims to use neuromodulation to treat the autonomic nervous system, which regulates bodily functions in MS such as sleep, stress, bladder control, and chronic pain. Although the present research has some limitations, such as a small sample size, future clinical trials may help to generalise the results. Nonetheless, the improvement found in this preliminary research offers Multiple Sclerosis patients an opportunity to improve their quality of life.

García, F., Fernández, D., Vázquez-Guerrero, J., Font, R., Moreno-Planas, B., Álamo-Arce, D., Medina-Ramírez, R., & Mallol-Soler, M. (2022). Recovery of the physiological status in professional basketball players using NESA neuromodulation treatment during different types of microcycles in season: A preliminary randomized clinical trial. Frontiers in Physiology, 13(November), 1-10. https://doi.org/10.3389/fphys.2022.1032020
Medina-Ramírez, R. I., Molina-Cedrés, F., Báez-Suárez, A., & Álamo-Arce, D. (2021). Nesa Non-Invasive Neuromodulation; A New Frontier of Treatment of the Autonomous Nervous System in Physiotherapy. CPQ Orthopaedics, 5(4), 01-04
Báez-Suárez, A., Padrón-Rodríguez, I., Castellano-Moreno, E., González-González, E., Quintana-Montesdeoca, M. P., & Medina-Ramirez, R. I. (2023). Application of non-invasive neuromodulation in children with neurodevelopmental disorders to improve their sleep quality and constipation. BMC Pediatrics, 23(1), 465. https://doi.org/10.1186/s12887-023-04307-4