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Sunday, June 10, 2012

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. 


 The inclusion criteria was:
1.       Females over 19 with CPP 
2.       Diagnoses included were pelvic adhesion, pelvic congestion syndrome, bladder pain syndrome, urethral pain syndrome, and IBS (excluded diagnoses were malignancy, primary dysmenorrheal, endometriosis, pregnancy, infections, active chronic PID, vulvodynia/vulvar pain syndrome) Interesting they removed a large part of the patients we see specifically vulvodynia
3.       Validated outcome measure
4.       Experimental intervention of PT alone or in combination with other medical or psychological therapies
5.       Prospective quantitative study design (retrospective studies or studies with historical controls were excluded)

There were 6 randomized clinical trials, 1 cohort study and 3 case studies.  Sample sizes ranged from 21 to 370 participants.  PT interventions, treatment frequencies and duration varied tremendously across the 11 studies.  Outcome measures also varied substantially across the studies.

Outcome/Results:  
1.       None of the data could be pooled for analysis because of the vast differences between the studies
2.       There was an inability to meta-analyze the results of the included studies which was a limitation in this review.
3.       The majority of the studies included in this review investigated the effect of PT in combination with medical or psychological treatment so the stand-alone value of PT treatment could not be determined.

 Conclusion:
1.       Based on the findings of this review, existing CPP clinical guidelines, textbooks on CPP and narrative reviews should be interpreted with caution.
2.       Current recommendations for specific PT treatments are not evidence based
3.       Only small, single studies have been undertaken of most of these interventions and that greatly limits available evidence on which clinical practice can be based.
4.       Primary research should be designed and conducted to test the effect of PT interventions for CPP since the available research is significantly lacking on multiple levels.

 Two treatments where somewhat effective – Mensendieck therapy (a hybrid of PT and cognitive behavioral therapy) and multi-disciplinary treatment.  Pointing out the importance of the psychological aspect.  A third treatment (distention of the PFM) was less effective but also included “pain counseling”.  Not surprisingly this paper graded ES and MFR not effective – the only two treatments not combined with psychological treatments. For more on Mensendieck therapy see https://oda.hio.no/jspui/bitstream/10642/1127/1/896167post.pdf

Thought Questions:
1.       What does this mean for current practice?
2.       What would be the results of the inclusion criteria was different?
3.       A major limitation is that there are no research studies that explore physical therapy (as an intervention) alone and that PT was included with multiple different disciplines in treatment of a patient but isn’t that how most of us treat CPP?  It takes a village…right?

 We have all been challenged to add to the body of research.  Certainly those who can produce RCT should and others who are more clinically based should publish case reports or case series. 

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