Pelvic PT distance journal
club
Aim: To
understand and compare the relative contribution of mucosal versus muscle pain
sensitivity with intercourse as reported from women with provoked vestibulodynia (PVD).
Background:
Estimated that 8.3%-16% of women experience
vulvovaginal discomfort in their lifetime and for many, it’s provoked
on contact, commonly referred to as provoked vestibulodynia (PVD).
Little is known about the
etiologies: PFM dysfunction and mucosal components, Or how abnormalities in muscle
form or function may impact pain during intercourse.
And, more information is
needed on the relationship of mucosal sensitivity to PFM
contracture/hypertonicity and potential pain and vice versa.
Subjects:. 54
women, primarily college educated (80%), married (87%), white women (84%) aged 31
years, of whom 81% were nulliparous
Subjects and data were taken from an original
study of 196 eligible women diagnosed with VVS during or after January 2002. Of these, 137 (70%) completed the
questionnaires and only 54 women met the inclusion/exclusion criteria (see
study).
Methods:
Proof of concept study nested in a
previous study of PVD : Cross-sectional questionnaire study, done between February 1, 2003 and October 31,
2005 and approved by the institutional
review board at the University of North Carolina at Chapel Hill. Initial study used 3-4 questionnaires including assessments for
psychological characteristics and self-reported . The current study only used data from one:
the Gracely scale.
Then the 54 were selected and given the physical exam.
The physical exam
included two tests to determine pressure pain thresholds (PPT): a cotton swab test of for vaginal mucosal sensitivity
and also a pelvic floor muscle test using a modified Jaeger’s technique
pressure algometer .
Two independent reviewers
abstracted the data from the exam and history from the medical records.
They divided the group
into two phenotypes of primary or secondary PVD. They were masked to the subject’s
questionnaire responses. High
agreement: out of 54 subjects, 20 had
primary PVD and 32 had secondary and 2 couldn’t be classified.
Mucosal sensitivity exam was described as a standardized approach (ref 18) to palpation and localization of individual
mucosal sites of the vestibule.
Six spots with the clock
reference: 3 anterior: 10:00, 12:00 and 2:00 and 3 posterior, which mirror the
anterior.
Anterior points of 2 and 10:00 found using
anatomical landmarks of a horizontal line through the urethral meatus and 12 as
being midpoint between the clitoris and the urethral meatus. Site 6:00 was most posterior.
Due to previous work with
an algometer they reportedly used pressure with a cotton swab corresponding to
1-1.5 Newton at each site. Pressure was
applied for about 1 and released for 2 seconds They began with anteriorly then
posteriorly: R, L then midline.
Following each palpation,
the patient rated it on the 0-10 Likert scale and the three points were
averaged for both the anterior then posterior regions.
Pelvic Muscle PPT measurements were taken with a modified Jaeger’s technique using the
index finger pressure calibrated with an algometer to an increment of
500g/s. Pressures vary from 500 g to up
to 3,000 g to assess muscle pain in the pelvic floor. Three muscle groups were assessed: 1)-
Perineal: posterior fibers of Bulbocavernosus converging with central midline
of Transverse Perineal at 6:00 and 2,3)- Right and Left Puborectalis , located
<.5 cm adjacent/behind midpoint of pubic rami, and 1-1.5 cm posteriorly “downward”).
Participants reported the
first onset of pain and the pressure was then stopped and that pressure:
pressure pain threshold ( PPT) was recorded.
Each site was tested 3x and then PPT was averaged.
For self-reported pain with intercourse, Gracely
Pain Scale was used.
Statistical analyses were done using SAS 9.1 They
used Student t-tests and composite average scores to average the mucosal and
muscle measures. Pearson’s correlation
was used to describe the subjective pain report with intercourse, and relate to
mucosal and muscle pain. It was also
used for correlations in the subgroups of PVD.
Significance was set to (P<0 .05="" all="" comparisons.="" in="" o:p="">
Results: With
the 0-10 pain scale, the average mucosal cotton swab rating was greater in the
lower vestibule at 5.81 (SD = 2.83) , vs the upper, at 2.52 (SD = 2.6) (P= .01). No difference in mucosal sensitivity between
primary vs secondary PVD
Slight but only marginally significant difference between groups, in self-reported maximal
severity of pain with intercourse :primary PVD: 87.1 (SD 10.8) and secondary: 72.9, (SD=24.8 ),
(P=.06) on 0-100 scale.
Correlation of the average mucosal pain rating for
the lower vestibule and with “components” of the modified Gracely scale for all
patients (r=0.38, P<.01) but there was no correlation with reported maximal
or minimal pain on intercourse and the pain on physical exam, for either
subgroup.
Muscle pain threshold varied at the 3 tested sites
from 500-2,000 g. The greatest
sensitivity (lowest PPT as low as 500g ) values were recorded in the perineal
muscle complex. Puborectalis was also
tender in this PVD population and only 4 patients reported tolerated pressures
as high as in healthy women ( 2,000 g).
Women with greater muscle tenderness (lower PPT)
reported more pain with intercourse : average and highest intercourse pain
significantly correlated with lower PPTs on exam (r=0.46, P= 0.01 and r=0.42,
P=0.02 respectively). (Figure 4)
There was a difference between the two groups in
muscle tenderness but it was not significant (P= 0.15).
Weaknesses and Limitations: 1) Continuous wide range of pressure vs a set amount
of pressure was given (but they said this was off-set by having one examiner
with a high within subject reproducibility of 200-300g).
2) They only looked at the
relationship between the “6:00 muscle” and the clinical pain report
3) They used a composite
score for the “lower vestibule” averaging for areas at 5,6 and 7:00. (They justified this due to previous study by
Zolnoun).
4) there were variable results
for muscle tenderness and inconsistent examination of pelvic muscles due to the
tester trying to minimize emotional aversion and discomfort of the primary PVD
group by using the same index finger of the R hand vs switching hands, (as with
the secondary PVD group).
5) They were limited in
evaluating mucosa in parous women as often the vulvar mucosa is replaced by
vaginal epithelium following childbirth.
They say the limited association between clinical pain report and
mucosal sensitivity may be explained in part by this challenge in assessment.
Strengths:
This study raises the question of the adequacy of relying on the
one-dimensional mucosal sensitivity test for diagnosis and classification of
patients with PVD. They point out that
the variance in sensitivity can also be due to neuromuscular dysfunction and
hypertonicity with referred neurogenic sensitivity. They have piloted and described a more
nuanced methodology for a more multidimensional assessment of pelvic pain (that
also includes a women’s report of pain).
They recommend further
studies on the effectiveness of various PT techniques such as STM, MFR, Dry
needling and core strengthening on muscle pain and dyspareunia.
Outcomes/Discussion:
This study
suggests there’s a difference between correlations between intercourse pain
report and pelvic muscle vs mucosal pain sensitivity (stronger correlation with
pain report and muscle sensitivity).
However, mucosal sensitivity was also correlated moderately.
There was no difference with mucosal sensitivity between
the primary and secondary PVD patient groups.
They stated they observed that the pattern of muscle
and pelvic floor sensitivity differed between the primary and secondary PVD
groups and that those with primary tended to be more sensitive at 5 and 7:00
and women with secondary at 6:00. They
said that since there were more women in the secondary group, the 6:00 position
(Bulbocavernosus and Transverse Perineal convergence) was the most positive.
Discussion Questions:
·
Will this alter your clinical assessment of patients with PVD, if so,
how?
·
How do you think the tester not changing hands with the primary PVD group
might have affected the outcomes, if at all?
·
Do you think they compromised the validity of the Gracely scale by using
“components” of it and if so, did that impact their outcomes?
·
What do you think about the VQ test as related to assessing for PVD?
·
What do you think about the muscles used in the study?
Addendum:
Questionnaires given in
initial study:
Pain
Questionnaire
A
Gracely Pain Scale was used to assess pain. This is the only study specifically mentioned
and used in the current proof of concept study: Women rated the lowest, average and maximal
pain with intercourse on a 0-100 scale.
They selected verbal descriptors by circling a word that best described
their pain including two pain domains of 1) sensory (severity of physical pain)
and 2) affective (emotional response to the level of physical pain). A predetermined numerical value for each
descriptor was averaged to give a summary score for statistical analysis.
(Modified versions of this have been used for pelvic
pain, such as below: Gracely Box scale (modified version) is of 21 boxes
sequentially numbered 0-20 (0 representing least amount of pain or distress)
and arranged vertically in two columns to correspond with increased amounts of
pain in one column or emotional distress in the other column. See reference to
view modified scale, I was unable to procure 100 point scale:
Gracely Box
scale measures of pelvic pain intensity (left)... - Scientific Figure on
ResearchGate. Available from:
https://www.researchgate.net/figure/221885490_fig2_Figure-2-Gracely-Box-scale-measures-of-pelvic-pain-intensity-left-and-unpleasantness
[accessed Oct 2, 2016]
Psychological
Questionnaires: administered
questionnaires to assess anxiety (Speilberger State-Trait Anxiety Inventory),
somatization (Pennebaker Inventory of Limbic Languidness), and global
psychological distress (Brief Symptom Inventory-Global Severity Index).
The following is a brief description of these questionnaires
The State-Trait Anxiety Inventory (STAI)
consists of two 20-item questionnaires, which assess an individual's current
anxiety level and general propensity towards anxiety. It has good reliability and the norm for
women is 36 on both scales.
The Pennebaker Inventory of Limbic Languidness
(PILL) assesses somatization by capturing the frequency of
occurrence of 54 common physical symptoms and sensations. It has “adequate”
test-re-test reliability and high internal consistency and the norm for females
is 98-104. A high somatization score is
an independent risk factor for chronic pain development and correlates with number
of muscle tenderness sites, pain
sensitivity and progression to chronicity.
The Brief Symptom Inventory (BSI)
consists of 53 items rating psychological distress in nine areas including:
somatization, obsessive-compulsive, interpersonal sensitivity, depression,
anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism.1A
global severity index (GSI) is obtained by combining the number and intensity
of reported symptoms. Test-retest
validity for the global severity index score is 0.90; the norm for the female
population is 50, with a clinical cut-off of 63.
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