Physical Therapy Journal Updates – December 2010 and January 2011

Physical therapist management of chronic prostatitis / chronic pelvic pain syndrome. Van Alstyne LS, Harrington KL, Haskvitz EM. Phys Ther 2010;90(12):1795-1806.

This is a great addition to the evidence for pelvic PT.  It is a very well done case study of 2 men with CPPS. This article can be used for marketing / insurance justification itself and has many other articles sited which could also be helpful.  The authors have done a very good job of summarizing the literature on CPPS dx, sx, tests, and rx. Both patients improved significantly within 12 visits and had complete resolution of symptoms on one year follow up.   

Examination techniques are well described and include many of the standards test used in orthopedic pelvic PT.  The authors point out that sudden pain associated with squatting is one of the symptoms of CPPS. FABER is also used but I am a bit confused as to whether they used it for testing obturator internus length or SIJ dysfunction.  Treatment is also described well including focused and aerobic exercises, relaxation, education and manual external and intrarectal manual treatments (including massage lateral to the prostate). I am a little confused on 2 of the exercises as the patients did not have pain on SLR but were given hamstring stretches and the bend knee fall out (an exercise I use from trunk stability) seems to be used for hip stretching. The authors used aerobic exercise well and sited a study showing decrease in NIH-CPSI scores in men who did aerobic exercises. 

I wanted to point out some information about the NIH Chronis prostatitis symptom index (NIH-CPSI).  This is a very patient friendly scale and I would recommend its use in the clinic.  The test itself has good psychometric properties (strong construct, face, and criterion validity, high internal consistency and retest reliability – references provided in article).  In addition we know an improvement of 6 points is the “optimal threshold to predict treatment response”.  A NIH-CPSI of higher than 50% meets the diagnostic criterion for CPPS.  Total high score 43, higher than 50% = 22. The authors also sited a study which showed a relationship of score of 22 or higher with internal PFM tenderness.  Another study reported patients with a score of greater than 15 were more likely lingering pain 12 months later. As I said this outcome measure is easy to administer and I would recommend it for clinic use in male pelvic pain. It is available on the SOWH CAPP- pelvic page under “common forms”. http://www.womenshealthapta.org/education/pelvic.cfm 

Primary care physical therapy in people with fibromyalgia: opportunities and boundaries within a monodisciplinary setting. Nijs J et al. Phys Ther 2010;90(12):1815-1822.

This article does a very good job at summarizing what we know about the mechanism of pain in fibromyalgia related to centralized pain.  It also looks at evidence in treatment.   Well done paper and worth reading even if you do not see many fibro patients.  I believe this treatment rational will also work with centralized pain related to chronic pelvic pain.

Most evidence available for

• Patient education on pain mechanism, stress management, life style modification, activity management (not over doing). 
• Aerobic and specific strengthening exercises

Less evidence but still helpful

• Trigger point injections
• TENS
• Joint mobilization
• Cognitive behavioral treatment of stress with or without biofeedback

Factors that influence the clinical decision making of novice and experienced physical therapists.  Wainwright SF et al. Phys Ther 2011;91(1):87-101. 

This article is of particular interest to teachers and contributes to the understanding of how experienced versus novice PTs think.  It points out that all PTs need life long learning and that this might be more difficult for experienced PTs.  I hope that this blog and the distance journal club offer an outlet for PTs of all levels to learn and grow.  I look forward to your participation in these projects.