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Sunday, January 18, 2015


Trigger points in pelvic pain - Comment on December's journal club by Sandra Gallagher

http://pelvicpt.blogspot.com/2014/12/december-pelvic-pt-distance-journal.html
http://pelvicpt.blogspot.com/2014/12/myofascial-trigger-points-of-pelvic.html

The  pain article that we discussed last night selected research data that supported what they wanted to develop as a protocol. A full review of trigger point research might not lead one to the same conclusion they made.  

I am not sure if you already reviewed this study in your distance learning calls.  

In my experience I hear people misrepresent the research or overstate the findings.  The Fitzgerald test was primarily looking at feasibility of a study considering would patient want to participate and can therapist adhere to the protocol.  it was a small n.  these are some points from the article that I think people who want to use it as justification for the internal painful MFR don't see or overlook.   

The ICA published the finding of this study as well I think they actually said the MPT was better the GTM  but this study's authors stated that the findings of this study could not make the conclusion.

"We also excluded patients who were intolerant to digital vaginal or rectal examination, ie unable to tolerate the MPT treatments. "

Patients were eligible to continue with study participation if some pelvic floor tenderness was elicited in any of the designated areas during this baseline pelvic examination. Patients without such tenderness were excluded from further participation.

 Extent of variation allowable by MPT group

During the time between visits, when deemed appropriate by the therapist, patients were asked to double void 2 to 3 times after each void (ie after voiding, to remain seated on the toilet and to relax or drop the pelvic floor again as if to initiate voiding). This was meant to facilitate a proprioceptive awareness of the movement of the pelvic floor during voiding, hoping to use recent recall to make dropping the pelvic floor easier. As their ability to drop the pelvic floor improved the patients could add 5 pelvic drops to the end of the exercise. Squatting was also taught as a position to use to facilitate and practice pelvic floor drops.

The treating physical therapist was permitted to vary the exact content of the hour-long MPT treatment based on the physical abnormalities present and on the response of tissues to manipulation. Initial treatments devoted at least half of the treatment time to external myofascial therapy. As connective tissue changes became evident with repetitive treatments, less time was typically needed for treatment of external tissues and more time was devoted to internal (transvaginal, transrectal) work. When the severity of symptoms prohibited transvaginal/trans- rectal myofascial trigger point release or CTM (although initial examination and inclusion of the patient was possible) this variance was allowed.

To maximize the potential for a treatment effect each therapist typically offered appropriate home exercises to each patient randomized to the MPT arm. Each therapist was provided with a catalog of stretches and/or exercises specifically chosen for this study and the appropriate exercise/stretch was given to the patient when desired by the therapist. Importantly these were not Kegel exercises which can increase the irritability of myofascial trigger points and exacerbate symptoms if practiced during an early phase of therapy. Later after muscle control is achieved a focus on improving muscle strength may be more appropriate and was permitted by the protocol.

GTM Treatment

Patients randomized to the GTM group received weekly massages consisting of full body Western massage for 1 hour. Unlike the MPT arm in which the therapists tailored the focus of therapy to target individual patient needs, GTM was used according to a common study protocol. This differs from clinically practiced therapeutic massage as the participating therapists were neither permitted to deviate from the GTM regimen nor to tailor the massage techniques to individual patients. Techniques used include effleurage, petrissage, friction, tapotement, vibration and kneading. These techniques were applied in upper and lower limbs, trunk, buttocks, abdomen, head and neck each for prescribed time periods (e.g. 10 minutes massage to head and neck). Patients randomized to GTM were not provided with a home exercise program. The GTM treatment was not similar to the MPT treatment with respect to the manual methods administered to the body tissues, ie there was no methodological overlap be- tween treatments. 

Adverse events were reported by 5 (21%) patients in the GTM group and 12 (52%) patients in the MPT group (table 3). Pain was the most common class of AEs as reported by 14 (30%) participants, of which 3 pain AEs were rated as severe (1 in GTM group and 2 in MPT group). 

Importantly this randomized controlled trial was not designed to assess whether myofascial physical therapy is superior to massage therapy for treatment of UCPPS. Such a study would have to allow for optimization of MPT according to the physical abnormalities that are present, and according to response to treatments and performance of massage therapy treatments by licensed massage therapists. Although physical therapists receive some training in massage therapy and are all licensed to practice massage, this is not a therapeutic modality routinely used by most physical therapists. We elected to have our physical therapists perform MPT and GTM treat- ments to avoid the confounding of therapist and treat- ment that would have been present if we had decided to have physical therapists perform the MPT and mas- sage therapists perform GTM. Importantly the GTM treatment used in this trial does not represent the standard of care for massage treatment and the results of this study should not be taken to mean that MPT is superior to massage therapy as would be prac- ticed by an expert for UCPPS.

Not mentioned by the study is that although the change is scores of outcome measures between the two groups was significant that the endpoint score of the GTM group was lower to start and lower as the endpoint.  I am not an expert in outcome measure but I do believe that they are not always linear and have ceiling and floor effects.

Sandra Gallagher

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