October 5, 2011 Pelvic Physiotherapy Distance Journal Club

This month’s journal club lead by Jane O’Brien focused on myofascial release and the treatment of pelvic pain. The difficulties in researching this modality are highlighted in the article presented.  The case study showcases the benefits of treatment. 

 

This month’s discussion

Fitzgerald MP, et al. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes.  J or Urol 2009;182:570-580.

Jane K. O’Brien , PT, MSPT.  Physical Therapy Management of a Patient with Dyspareunia and Scoliosis: A Case Report. Unpublished case report using myofascial release.

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2011 schedule

May 4 – Jane O’Brien

June 8 – Pam Downey

July 6 – Ann Dunbar

August 10 – Michelle Spicka

September 7 – Pam Downey

October 5 – Jane O’Brien

November 9 – Beth Shelly

December 7 – Michelle Spicka

Physical Therapy Management of a Patient with Dyspareunia and Scoliosis: A Case Report

Jane K. O’Brien, PT, MSPT

revised 7.20.11

CASE DESCRIPTION

Full case report and tables available at http://www.northtahoept.com/documents/case_study_7.18.11_edit_7.20_AMC2_.pdf

History

 The patient was a 69 year old married woman who was self-referred to physical therapy. Her chief complaint was dyspareunia or painful intercourse. She reported that upon penetration her pain was deep in the vagina. She also complained of hip pain with intercourse when she assumed a position of combined hip flexion, abduction and external rotation. The patient had not engaged in intercourse for 14 years prior to her first PT appointment due to a dispute with her husband.  They both desired reconciliation, and after they attempted to engage in intercourse and discovered that her pain prevented the activity, the patient sought out physical therapy for her dyspareunia.

The patient’s OB/Gyn history included 2 live births which were vaginal deliveries. Her Medical history included a structural scoliosis (left thoracic, right lumbar), with DJD of the right hip. She had a history of cortisone injections in the right hip to alleviate the pain.  She had experienced lack of sleep and loss of weight over the last year due to marital problems. She also reported a history of GERD, hysterectomy, and asthma. Medicines listed were Singulair, Nexium, Plavix and Norvasc. Overall, she reported that she was in good health.

Review of Systems

Reviews of the neurologic, cardiopulmonary, and integumentary systems were unremarkable.

Test and Measures

The patient was given 3 outcome measures upon initial evaluation. She rated her pain as 10 of 10.  On the Vulvar Pain Functional Questionnaire (VQ), she scored a 5 out of a possible 33.  A lower number on this scale indicates a greater pain level.  She was evaluated with the NIH- Chronic Prostatitis Symptom Index (NIH CPSI). On the pain domain, she scored 10 and indicated that her pain was below her pubic area and she experienced pain during or after sexual climax.  For urinary symptoms she scored 1, and for quality of life she scored 5 and indicated that she was mostly dissatisfied with her symptoms. Her NIH-CPSI total score was 16.

Musculoskeletal assessment review began with observation of the patient’s posture in standing. She was observed from the anterior, lateral and posterior views. According to McGee, the pelvis is usually the key to proper back posture (McGee 2008).  Observation of the pelvis revealed the right ileum was higher than the left ileum.  The client’s spine was laterally curved to the right in the thoracic region and to the left in the lumbar region.  Her right rib cage appeared more caudal making the right waist appear compressed.  The client’s scoliosis remained present on forward flexion.  These findings were consistent with a right thoracic, left lumbar structural scoliotic curve (Kisner and Colby 2007).  ASIS was palpated and found to be lower on the right, and the PSIS was higher on the right.  The patient was then observed in supine and prone. Palpation of bony landmarks of the lumbar spine, pelvis and sacrum was performed to assess symmetry. The right ASIS was more caudal relative to the left. The right PSIS was more cranial relative the left. These findings indicated an anteriorly rotated right ileum.

The exam then focused on the lumbar spine, sacroiliac and hip joints. Lumbar active ROM was full in flexion. Extension was uncomfortable. Repeated extension increased her discomfort level. Repeated flexion was pain free. It was determined that she had a bias for lumbar flexion. Segmental lumbar mobility was also limited. Results from measurements of the active range of motion of the hips are shown in table 1. 

Passive flexibility of the hips was determined by moving the hips into combined flexion, abduction, external rotation.  A limitation of 50% was found in the left hip relative to the right.  Manual muscle testing (MMT), as described by Daniels and Worthingham (1986), of the bilateral hip muscles indicated hip weakness.   Gluteus Medius strength was 3+ on the right and 4+ on the left. Bilateral piriformis tenderness was present.

An internal pelvic floor muscle (PFM) assessment was then performed. Written consent for evaluation and treatment of the pelvic floor had been obtained when the patient filled out the initial paperwork since her chief complaint was that of dyspareunia. The examination was performed in the supine hook lying position.  Palpation of the external PF musculature was unremarkable. The examination then continued internally through the vagina using palpation with one digit (Bo and Sherburn 2005).  Palpation of the levator ani and the obturator internus muscles reproduced the pain she had experienced during intercourse. Pelvic floor muscle strength was not assessed since patient did not present with symptoms associated with PFM weakness.

Evaluation/Diagnostics

The examination revealed a right trunk compression, poor hip flexion and asymmetry of motion, pelvic floor tension and MTrP in the PFM.  It was hypothesized that her scoliosis created abnormal posturing which affected spinal and pelvic floor muscle length.  Treatment was directed at correction of the scoliosis and pelvic tilt by alteration of the fascial tension in the trunk and pelvis. ICD 9 codes used were 729.5, limb pain and 728.85, muscle spasm. Treatment frequency was set for 2-3 times per week. 

Prognosis was listed as “Good” since the patient was in good health, was highly functional despite her pelvic pain, and was greatly motivated to succeed. Expectations were that the patient could achieve her goal of pain free intercourse within the next 30 days.                          

Intervention

During the first appointment, the initial evaluation was performed and the book Sex and Back Pain, by Hebert (Hebert 1997) was reviewed with the patient. She was taught to perform lower extremity stretches for the hip region based upon myofascial release principles as described by Stedronsky et al. (2006). The stretches included the FABER stretch (combined flexion, abduction, external rotation), Hamstring elongation, and double knee to chest. She was instructed to hold all stretches for 90-120 seconds.  Deep breathing with a mental focus on the breath flowing into the muscles was emphasized during the stretch. She was asked to take the stretch to the beginning of the barrier and hold. As the barrier released, she was instructed to sink further into the stretch until she felt the next barrier. This method was also included in the home exercise program.

On the second and successive visits, treatment consisted of manual therapy, a gym program and patient education. Details of daily findings and treatment are shown in Table 3. Myofascial Release techniques as described by Barnes (1990) were often employed and included the use of DeJarnette blocks manufactured by Sorsi. Pilates exercises, as well as core stabilization exercises as described by Sahrman (2001), were major components of the gym program.

To determine proper continued treatment, the position of the pelvis was assessed and monitored at the beginning and end of each session. Neville (2008) describes the pelvic ring as “the foundation of the house” and proposes that a key component to proper pelvic floor muscle function is restoration and maintenance of optimal pelvic ring alignment. Because a leg pull releases fascial restrictions in the right lower quadrant, the lower extremity, and into the pelvis (Barnes, J 1992), this myofascial release technique was used to restore alignment and balance to the pelvis.  Additionally, DeJarnette blocks were used numerous times in treatment, both in prone and supine as described by Barnes (1992), to reposition the pelvis.    

The client was receiving treatments 2-3 times a week, thus self-care was mandated and the patient was instructed to perform daily pelvis balancing exercises to assure proper joint alignment and mobility.  On the fourth visit, the patient reported decreased pain with penetration, but continued biomechanical difficulties with intercourse due to her poor hip ROM and pain. 

On her sixth visit, the patient reported that hip pain and poor ROM were her only limitation to intercourse. She had no penetration pain.  The patient was scheduled for a 16 day vacation. She was instructed to perform her hip stretches daily while away.

When the client returned to the clinic, she complained of right sided low back pain. She was treated 3 additional times with MFR and altered her home program to include self-mobilization techniques. When she was discharged on the 9th visit, she reported no internal pain with intercourse. She simply had hip pain. The patient’s hip ROM measurements were taken and are shown in table 2.

Outcomes

The patient completed her course of therapy in 9 visits with complete resolution of her dyspareunia. 

Initial scores on outcome measures compared to final scores were excellent. The patient’s initial dyspareunia rating was 10 of 10; after completion of treatment her rating was 0 of 10.  Unfortunately, the client failed to return her final VQ index; an index which is known to demonstrate excellent test/retest reliability and internal consistency (Hummel-Berry et al 2007).  However, the NIH-CPSI is a well-accepted tool for the evaluation of patients with chronic pelvic pain syndrome. It has been found to have high reliability and construct validity as a tool to quantify pelvic pain syndromes (Litwin et al 1999). The patient’s original NIH-CPSI score was 16, her final score was 0.

Low back pain had become the patient’s chief complaint after her 16 day hiatus.  This patient was later evaluated for low back pain and a new plan of care was formulated. During those 13 treatments, she experienced no dyspareunia and reported an active sex life. The client was contacted 9 months after discharge from her original diagnosis. She reported revitalization in her marriage and her relationship with no recurrence of sexual dysfunction or low back pain.

Randomized Multicenter feasibility trial of myofascial physical therapy for treatment of urological Chronic pelvic pain syndromes

Purpose: To determine feasibility of conducting a RCT Myofascial PT (MPT) vs. global therapeutic massage (GTM) for UCPPS.

• MPT—Internal pelvic and external TP work, PFM, hip, abdomen
• GMT—Western massage; nonspecific.
• Urologic CPP syndromes includes IC/PBS and CP/Chronic pelvic pain.. c’stics pelvic pain and urinary sx.

1. PBS (ICS) complaint of suprapubic pain relates to bladder filling with other symptoms. Ie: increased day and night frequency, without urinary infection other pathology. May be related to IC—relationship is not clear.

2. CP/CPP Diagnosis is based on symptoms and without urodynamics or a cystoscopy. Pelvic pain lower urinary tract. Symptoms in absence of other urinary infection or other pathology.

3. IC (1990) 500,000 people affected in US 25% less than 25 years old.

• Belief is that myofascial tension contributes to the pain of UCPPS
• Are they a consequence (secondary PFM) or is it disorder which leads to urinary symptoms. (chicken or the egg?)
• Reports of Symptom relief from Rx to muscles (by PTs doing manual PT, A common practice) No RCTs showing effectiveness of pelvic floor and external PT for UCPPS

Eligibility-

Adults with diagnosis of IC/PBS pr CP/CPPS, less than 3 years symptoms. Must have under gone at least one other form of therapy for symptoms. Exam shows tension tenderness of PFMs and somatic tissues in UCPPS. Excluded: Those who could not tolerate digital exam ( myofascial PT) and those who had previously undergone MPT for sx..

47 subjects with CP/CPP or IC/PBS at 6 centers

23 men, 24 women, 24 for GTM, 23 for MPT, 44 completed study

10 Rx, 1 hour each

Criteria to assess feasibility

1. Adherence of patients to therapy protocol. Excellent

2. Adverse events during study

3. Rate of response to therapy—57% in MPT, 21% in GTM

OTHER CONSIDERATIONS:

1. Are patients willing to be in 1 group or the other?

2. Can physicians identify relevant MF abnormalities in an exam?

3. Assure manual pt is similar in different sites (quality and nature)

4. Assess safety of manual PT for UCPPS and determine response rate

PT Certification.

1. Already doing manual RX on patients with UCPPS

2. 2 PT’s / site

3. Study materials / DVD

4. Weekend course, practiced on volunteers.

5. Did 5 Rx’s of each type

Potential Participants

First visit of study:

Questions/ symptom scales

Pain questionnaire on average pain, pelvic bladder discomfort

Urge/frequency/severity on average for last 4 weeks

IC symptom and problem index

NIH/CPSIC males

SF-12 health status questions

Gender specific functional index( FSFI or sexual Health inventory for Men)

Pelvic exam by study physician...If No TP’s...they were excluded

Second study visit

PT Exam of muscle/soft tissue

Ok to continue if PT confirmed that they were tender on pelvic exam. didn’t have to correlate to MD’s area of tenderness. Also, mapped scars and Ct restrictions and eval’d soft tissues of  v=back, hip, abdom and PF.

Divided up to MPT/GMT 10 sessions 1 hour/ week

MTP Rx= C.T manipulation to areas with TP’s and/or CT abnormalities (not defined)

In the: Abdominal wall, Back, Buttocks, Thighs

A. Prone

1. CTM posteriorly from inferior T-10 popliteal crease until tissues texture changed.

2. For TP’s TP barrier release with or without active contraction or RI. Manual stretching

of TP region and MFR on TP’s

B. Supine

1. CTM to (B) anterior tissues—thighs (knees to thigh crease). Abdominal wall (suprapubic rim to anterior costal cartilage). Manual TP release to Scars and TP’s—in ant and post LQ. Especially episiotomy scars.

For TP’s

C. Transvaginal/transrectal treatment of PFM/s with CTM of periurethral tissues, AT Fascial pelvis, Muscle O and I’s. NMRe-ed to lengthen PFM’s with Myofascial manipulation including post isometric relaxation.

• Between visits: Double void—void, relax or drop PF to initiate voiding... up to 5, as ability improved Squatting taught to practice Pelvic floor drops.
• Rx’s ok to vary content based on findings, but, initially ½ Rx time was external MFR . Over time, External decreased, move to internal.
• HEP—according to catalogs of stretches/strengthening for study. No kegels early on.

GTM Rx; Weekly full body western massage 1 hour

Effleurage, Petrisage, friction, tapotment vibration,kneading . UE, LE, Trunk, Buttocks, Abdomen, Head, Neck for prescribed time. No HEP. No deviation from protocol

Rx ended when subject completed Rx and outcome assessment. Dropped out, D/C by MD.

Results:

• Participants 24 GMT 23 MPT
• IC/PBS = 24 women, 2 men
• CP/CPPS = 21 men
• 44 completed study
• Demographics Mean age=43, 41 were white
• Med # Rx, (10) adherence to protocol (excellent) All of allowed interventions were used some of time, most common = CTM to LE, Abdomen, buttocks, PFM and TP’s, abdom and PFM
• Adverse Events reported by 5 (21%) for GMT and 12 (52%) for MPT.. Pain most common 14( 30%), of which 1 was severe.
• Global Response Assessment response Rates: MPT 57% GMT 21% (responders are reported as those reporting markedly improved or moderately improved.)

Base line & 12 week symptom scores:

• MPT- improvement for IC/PBS and CP/CPP.
• GMT no significant improvement for IC/PBS but did see improvements with CP/CPP in pain, QOL & ICSI
• Sexual function improved for MPT IC/PBS not for CP/CPP
• SF-12 unaffected physical and mental component for both IC and CP for GMT
• Physician Internal muscle tenderness/pain to palpation across the 4 muscle groups:
• Baseline 17.78, 12 week final eval 10.96
• MPT-significant relief compared to GTM
• MPT-relief from TP’s for CP/CPP
• GTM- anterior and posterior levator relieved.

Discussion

Authors say they demonstrated that such a clinical trial is feasible and pt’s were willing to be randomized to 1 group or another. Able to standardize both treatment approaches with almost complete adherence to prescribed Rx for GTM and MPT. Low AE

57% response rate shows MPT as a meaningful Rx option. Could have been a challenge if patient expected immediate resolution or unwillingness to ge in group with unproven Rx. Interesting difference of RR with GTM CP 40% (all women) IC 7% (all but 2 men)

Do males respond differently to GTM?

Does CP respond differently to GTM?

Limitations

• Unable to blind study participants to Rx group.
• PT’s may be biased doing GTM
• This study does not mean MPT is superior to GTM for Rx of UCPP’s

Conclusion

Full scale trial of MPT for Patients with UCPPs is possible And beneficial effects of MPT warrants further study.

Journal club Discussion Questions/Ideas

1. Can you truly guarantee skill level, similar treatment between PT’s doing manual therapy?

2. Different response of men and women to GTM seems study needs to be done on this with just women or on CP to GTM vs MPT within 1 gender.

3. MPT included a lot of treatment options. Any thoughts on this?

4. Scales they used to measure response rates.