Somatocognitive therapy in the management of chronic gynaecological pain. A review of the historical background and results of a current approach.

Gro Killi Haugstad, MHS, PhD, Unni Kirste, MD, Siv Leganger, MPs, Elin Haakonsen, MHS and Tor S. Haugstad, MD, PhD.

 This concept was discussed at the last journal club meeting.  It was one of the only treatments with evidence of success.  http://pelvicpt.blogspot.com/2012/06/does-evidence-support-physiotherapy.html   The entire paper is available on line https://oda.hio.no/jspui/bitstream/10642/1127/1/896167post.pdf     and describes the technique fairly well.   Watch for July journal club article email on July 2^nd.

 “Somatocognitive therapy - a hybrid of physiotherapy and cognitive psychotherapy. Focusing on the present cognitive content of the mind of the patient, and acknowledging the important role of the body in pain-eliciting defense mechanisms against mental stress and negative emotions..

The core of this somatocognitive therapy is to 1) promote awareness of own body, 2) graded task assignment related to the motor patterns utilized in daily activities, 3) combined with an empathic attitude built on dialogue and mutual understanding, and emotional containment and support. The goal is for the patient to develop coping strategies and mastery of own life. In addition, 4) manual release of tensed muscles and applied relaxation techniques are important.”

Comparisons of pelvic floor muscle performance, anxiety, quality of life and life stress in women with dry overactive bladder compared with asymptomatic women.

Sharon Knight, Janis Luft, Sanae Nakagawa, Wendy B. Katzman, BJU International Volume 109, Issue 11, pages 1685–1689, June 2012.

“RESULTS - Anxiety scores were significantly higher in women with dry OAB than in controls. No significant differences were found in sEMG measures of pelvic muscle contraction or relaxation. There was no significant correlation between sEMG pretest resting baseline measurements and the Beck Anxiety Inventory, the Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire or life stress scores among symptomatic women.”

In other words, the PFM is not dysfunctional in every patient with UI.  It is important to list impairments correctly.  If the muscle is normal do not list it as underactive.  Sometimes I use “PFM in-coordination” as I think it more clearly identifies the issue.  PFM contractions can help but not because the patient has weakness but because it does not contract at the correct time.  Rhythmical contractions can also affect the nerves to the bladder.   

 This study also points out, we must be aware of (and providing input for) the patient’s anxiety around urgency.  Most PTs realize that anxiety increases urgency but I am afraid, sometimes, the PT focuses too much on the PFM (which might be normal) and too little on the nerves to the bladder which desperately need training.

Associations of Commonly Used Medications with Urinary Incontinence in a Community Based Sample

Susan A. Hall, May Yang, Margaret A. Gates,  William D. Steers,  Sharon L. Tennstedt, John B. McKinlay, The Journal of Urology, Volume 188, Issue 1 , Pages 183-189, July 2012

 After final multivariate adjustment there were significant positive associations for certain antihistamines, beta receptor agonists, angiotensin II receptor blockers and estrogens with UIU in women, and a borderline significant association for anticonvulsants. Among men only anticonvulsants were associated with UI after final adjustments, angiotensin II receptor blockers showed an adjusted association of borderline significance.

Very important for all pelvic PTs to monitor medication influence.

G-spot and multi-disciplinary treatment of perienal pain

Is the Female G-Spot Truly a Distinct Anatomic Entity? Amichai Kilchevsky, Yoram Vardi, Lior Lowenstein and Ilan Gruenwald, J of Sexual Med 2012;9(3):719-726.  This literature search looked at many research papers trying to reproduce, map, and image the location of the female G spot with reproducible and consistent means.  And the answer is….. “Objective measures have failed to provide strong and consistent evidence for the existence of an anatomical site that could be related to the famed G-spot”. 

 G-spot anatomy: A new discovery. Ostrzenski A. J Sex Med 2012;9:1355–1359.  Same journal several issues later.  I can only see the abstract but it looks like a dissection study.  Very specific as to the location and size. 

 Provoked Vestibulodynia—Women's Experience of Participating in a Multidisciplinary Vulvodynia Program. Leslie A. Sadownik, Brooke N. Seal and Lori A. Brotto Journal of sexual med 2012;9(4):1086-1093.  This semi-structured interview process asked women with vestibulodynia about their experience in a multi-disciplinary program. Five themes emerged – increased knowledge, gaining tools and skills, perceived improved mood and psychological well-being, sense of validation and support, and an enhanced sense of empowerment.  The multi-disciplinary approach was seen as overall beneficial.  Certainly this makes sense in light of the new evidence of the benefits of cognitive behavioral therapy in chronic pelvic pain.  Working together as a team is best for the patient. 

How well is the multi-disciplinary model working? Rosenbaaum T, J Sex Med 2011;8:2957-2958.  This and many other articles are available on Talli’s web site.  http://www.tallirosenbaum.com/en/en_pubs_index She has done a good job to bring to light the importance of this approach.  All PTs should be embracing these concepts. 

Sexual Function and Quality of Life of Women with Stress Urinary Incontinence: A Randomized Controlled Trial Comparing the Paula Method to Pelvic Floor Muscle Training Exercises. Liebergall-Wischnitzer M, Paltiel O, Celnikier D, Lavy Y, Manor O, Wruble A. J Sex Med. 2012, 9(6):1491-1721.

Pelvic Physiotherapy Distance Journal Club June 6, 2012

Michelle Spicka, DPT

Objective:  Comparing the effectiveness of the Paula method vs. the PFMT (pelvic floor muscle training) on sexual function (SF) and quality of life (QoL) of women with SUI.

The Paula Method is a circular muscle exercise protocol that works on the premise that all sphincters in the body are synchronized with the movement of one affecting the other.  The Paula method theory claims that one can rehabilitate damaged muscles by contracting and relaxing specific “circular” muscles in other areas of the body.  The exact mechanism is unknown though speculations have been raised that one sphincter affects others due to oscillations in the spinal cord.  The Paula method has been used in Israel for several decades and found to be effective in some clinical trials.

Does evidence support physiotherapy management of adult female chronic pelvic pain? A systematic review. Loving S, Nordling J, Jaszczak P, Thomsen T. Scandinavian Journal of Pain 3 (2012) 70-81.

Pelvic Physiotherapy Distance Journal Club June 6, 2012

Michelle Spicka, DPT

Objective:  To examine evidence for an effect of physiotherapy as a sole intervention or significant component of a multidisciplinary intervention on pain.

 Study Design/Method:  The research strategy identified 3469 potential articles but only 11 articles (representing 10 studies) met the inclusion criteria. 

NEW - AUA Guideline on OAB

American Urological Association (AUA) Guideline - DIAGNOSIS AND TREATMENT OF OVERACTIVE BLADDER (Non-Neurogenic) IN ADULTS: AUA/SUFU GUIDELINE

  E. Ann Gormley, Deborah J. Lightner, Kathryn L. Burgio, Toby C. Chai, J. Quentin Clemens, Daniel J. Culkin, Anurag Kumar Das, Harris Emilio Foster, Jr., Harriette Miles Scarpero, Christopher D. Tessier, Sandip Prasan Vasavada

  Approved by the AUA Board of Directors May 2012

 “First-Line Treatments:

6. Clinicians should offer behavioral therapies (e.g., bladder training, bladder control strategies, pelvic floor muscle training, fluid management) as first line therapy to all patients with OAB. Standard (Evidence Strength Grade B)

7. Behavioral therapies may be combined with anti-muscarinic therapies. Recommendation (Evidence Strength Grade C)”

 http://www.auanet.org/content/media/OAB_guideline.pdf

http://www.auanet.org/content/media/OAB_algorithm.pdf

http://webcasts.prous.com/AUA2012/html/1-en/template.aspx?section=7&p=7,22462

 AUA meetings are web cast and free access for all. 

http://webcasts.prous.com/AUA2012/html/1-en/template.aspx?section=1

There are several interesting presentations.  This is one I found interesting  – this report summarized some of the current issues in UI.  Take a listen.  I hope all urologists do.

http://webcasts.prous.com/AUA2012/html/1-en/template.aspx?section=7&p=7,22529