Physical exam findings by physical therapists compared with physicians of musculoskeletal factors in women with chronic pelvic pain Journal of the Section on Women's Health, Sept- Dec 2010, pp73-79

Introduction: PTs and physiatrist have extensive MS training. Purpose was to compare ability of physiatrist and PTs ability to differentiate women with CPP from those without it.

Methods:

48 non pregnant women aged 18-55, mean age 35, CCP group and non pain group

4 blinded examiners (2 MD, 2 PT), 1 MD and 1 PT would see pt 30 minutes apart and do the MS exam maneuvers.  Goal was to diagnosis / identify CPP.  This is quite different from evaluating a patient to determine a PT plan of care.

There were 13 tests originally.    

9 tests kept:

·        posture (amount of lordosis),

·        Trendelenberg (test is listed incorrectly, should say “the hip on the non stance leg drops),

·        hip ROM (prone IR, ER, supine abduction, adduction),

·        Faber,

·        forced Faber,

·        P4,

·        abdominal muscle strength (leg extension without increased lordosis),

·        PFM tenderness,

·        PFM strength.

4 were thrown out due to false positive results in the non pain group. Gillet’s, Standing flexion and pelvic symmetry removed because a majority of pain free clients scored positively for pain on these.  ASLR removed because it was negative for all participants in both groups.  This is partly because the interpretation of the ASLR was related to pain only – not difficulty as it is typically written.  These tests may have some use in creating a POC after the diagnosis of CPP is made.

Does this help show that mobility tests are not as reliable in diagnosising CPP as pain provoking tests?  In our discussion, the reproducibility of these tests between colleagues was questioned.

Results:

PT's generally reported a higher number of positive responses, MD's generally reported higher number of false positives. PTs differentiated 85% of CPP participants whereas MDs differentiated 69%. Study shows value of PTs as musculoskeletal specialists.

Substantial interexaminer agreement

·         P4 .75

·         Forced Faber .71

·         Faber .71   

Moderate interexaminer agreement

·         PFM tenderness .58

·         Trendelenberg .42

·         Hip ROM .42

Percent agreement

·         P4 87.5%

·         Forced Faber 85.4%

·         PFM tenderness 79.2%

·         Faber test 76%

·         Trendelenberg 70.8%

·         Hip ROM 60.4%

Conclusion:

Current literature suggests MS factors contribute to CPP in females.  PT’s have more experience in examining and treating MS problems so may be more able to identify MS sources of CPP. Interdisciplinary standardized training among MD and PT could be beneficial. This study can help practitioners identify relevant musculoskeletal tests to use for diagnosing and developing treatment strategy. 

Study shows value of PTs as MS specialists as PTs. PTs should be considered first line practitioners in evaluation and treatment of female pelvic pain to make earlier and more precise dx, and treatment. Good finding for direct access. This article could be used as a marketing tool for PTs to educate doctors about the relevance and skill level of women's health PTs

Discussion

Some were surprised by tests that were thrown out. Author pointed out that Gillet test is good to validate SIJ pain once CPP diagnosis is made. It can help indicate mobility problems, not helpful to make a diagnosis. Author uses the test to formulate a treatment strategy.

It is suggested that physicians perform P4, forced FABER, FABER, and palpation of PFM.  These are robust tests and help to identify patients who would benefit from referral to women's health PT for MS evaluation and treatment.

This is further evidence that our young PTs need good orthopedic training.

We PTs need to educate the consumer at women's health events and in publication as to the role of PT in MS CPP.

Pelvic PT Distance Journal Club 5/4/11

Jane O’Brien