Chronic pelvic pain: Pelvic floor problems, sacro-iliac dysfunction and the trigger point connection

Muscles and Central Neural Networks Involved in Breathing: State of the Art

Breathing is a systemic act, which involves not only the lungs, but the entire body system. To have a comprehensive clinical picture, it is necessary to have all the patient's data; from this assumption, we can affirm that it is necessary to know all the muscles involved in breathing to understand how to obtain a comprehensive approach for the care and treatment of the patient to improve respiratory capacity. The text reviews the efferent connections of the respiratory centers and cites all the muscles that are involved in the mechanism of breathing and that are controlled and managed by the respiratory centers, starting from the muscular description of the cranial area, the bucco-cervical area, the cervicothoracic area, and the thoracic area. Knowing the function of the respiratory accessory muscles allows us to obtain, in some clinical cases, valuable data that can prove predictive of the diagnostic path of the pathology. This is the first article in the literature, to the authors' knowledge, that attempts to list and include in a single text all the muscles directly or indirectly involved in breathing. The goal of this narrative review article is to remind clinicians and researchers involved in the study of different muscular respiratory responses that we need to analyze and work all the skeletal musculature involved in breathing to better understand what happens in the pathological or physiological phases during breathing. This step will allow us to better individualize the therapeutic and training approach for healthy subjects.

A directional preference approach for chronic pelvic pain, bladder dysfunction and concurrent musculoskeletal symptoms: a case series

BACKGROUND

Chronic pelvic pain (CPP) with concurrent musculoskeletal and bladder symptoms is a complex and challenging problem. However, clinically the co-existence of these symptoms is not routinely questioned, and their musculoskeletal source is not investigated thoroughly. The purpose of this case series is to present the use of Mechanical Diagnosis and Therapy (MDT) principles in seven patients with concurrent chronic pelvic pain, bladder dysfunction and musculoskeletal symptoms.

CASE DESCRIPTIONS

Seven patients with coexisting pelvic health and musculoskeletal signs and symptoms were retrospectively reviewed. Most common symptoms were urinary frequency, incontinence, pelvic pain, nocturia, dyspareunia, bladder dyssynergia, and lumbar, pelvic or hip pain. All patients failed to recognize the possible interconnectedness of the two sets of symptoms. Each exhibited a directional preference (DP) and subsequent MDT provisional classification of derangement was established; the use of DP forces abolished or dramatically improved both symptoms and mobility impairments. In all cases DP was for sustained sagittal forces initially, but ultimately lateral forces and mobilization were indicated.

OUTCOMES

Changes in Pelvic Floor Impact Questionnaire, Care Connections Pelvic Floor and Lumbar spine were all clinically significant and exceeded minimally Clinical Important Differences several times. Average of 5.8 sessions per patient was noted. Follow-up at an average of 3.3 years revealed ongoing satisfaction and confidence in independent self-management.

DISCUSSION

These case studies highlight the importance of ensuring expansion of intake questions for possible co-existence of symptoms in both pelvic and musculoskeletal patients, possibly suggesting a mechanical intervention is indicated. Provisional subclassification into 'Mechanical Pelvic Syndrome' is proposed. Level of Evidence: 4.

[Physiotherapeutic assessment of chronic pelvic pain syndrome : Development of a standardized physiotherapeutic assessment instrument for interprofessional cooperation in patients with chronic pelvic pain syndrome]

BACKGROUND

The chronic pelvic pain syndrome (CPPS) can be associated with physiotherapeutic findings. An interprofessional approach is recommended for patients with CPPS; however, no standardized physiotherapeutic assessment and documentation instrument for specific physiotherapeutic assessments exist, which is not only the foundation for physiotherapy but also for interprofessional communication.

OBJECTIVE

The aim was the development of a physiotherapeutic assessment instrument for patients with CPPS and therefore, to create a tool for clinical use, research and interprofessional communication.

MATERIAL AND METHODS

Based on an explorative literature search and an expert consensus, the first version of the instrument was developed as part of a specialized outpatient clinic. This version was applied clinically for 13 months, edited and finalized after another expert consensus.

RESULTS

The developed instrument Physical Therapy Assessment for Chronic Pelvic Pain Syndrome (PTA-CPPS) lists external and internal groups of muscles for a systematic assessment of myofascial findings. Functional capacity, breathing movements as well as scars and regions of pain are recorded. A manual for the assessment protocol was developed as accompanying material.

CONCLUSION

The developed instrument provides for the first time a physiotherapeutic assessment tool for patients with CPPS for interprofessional clinical and scientific use.

Physiotherapy management of patients with chronic pelvic pain (CPP): A systematic review

INTRODUCTION

Chronic pelvic pain (CPP) is a common pain condition. However, treatment remains challenging. Musculoskeletal findings are frequent; therefore physiotherapy might be helpful. The purpose of this review was to evaluate the current evidence on physiotherapy in patients with CPP (PROSPERO registration number CRD42016037516).

METHODS

Six databases were searched and additional hand searches were performed. Two reviewers independently conducted the database search and selected studies using a two-step approach. The methodological quality was assessed applying the Critical Review Form - Quantitative Studies.

RESULTS

A total of eight studies were included. Trigger point therapy was examined in four studies; two of which were randomized controlled trials. All studies indicate a significant change in pain measurement. The other four studies evaluated the effect of biofeedback, Thiele massage, Mensendieck somatocognitive therapy and aerobic exercises, whereas the last two were tested in controlled trials. All studies showed significant improvements in pain assessment.

CONCLUSIONS

The evidence currently available is sparse with methodological flaws, making it difficult to recommend a specific physiotherapy option. There is an urgent need for high-quality randomized controlled trials to identify the most effective physiotherapy management strategy for patients with CPP.

Sacroiliac Pain: A Clinical Approach for the Neurosurgeon

Pain originating from sacroiliac joint may also cause pain in the lumbar and gluteal region in 15% of the population. The clinical manifestation represents a public health problem due to the great implications on the quality of life and health-related costs. However, this is a diagnosis that is usually ignored in the general clinical practice; probably because of the unknown etiology, making harder to rule out the potential etiologies of this pathology, or maybe because the clinical criteria that support this pathology are unknown. By describing several diagnostic techniques, many authors have studied the prevalence of this pathology, finding more positive data than expected; coming to the conclusion that even though there is no diagnostic gold standard yet, an important amount of cases might be detected by properly applying several tests at the physical examination. Thus, it is necessary to have knowledge of the physiopathology and clinical presentation so that diagnosis can be made to those patients that manifest this problem. We present a clinical approach for the neurosurgeon.

Chiropractic management of chronic idiopathic meralgia paresthetica: a case study

OBJECTIVES

This report describes the case of a patient with chronic idiopathic meralgia paresthetica associated with bilateral sacroiliac joint dysfunction who was managed with chiropractic care.

CLINICAL FEATURES

A 35-year-old white woman presented to a private chiropractic clinic with a complaint of numbness in the right anterolateral thigh region. Neurological assessment revealed a diminution of sensibility and discrimination on the right lateral femoral cutaneous nerve territory. Pain was rated as 8.5 on a numeric pain scale of 0 to 10. Musculoskeletal examination of the pelvic region disclosed bilateral sacroiliac joint dysfunction.

INTERVENTION AND OUTCOMES

Chiropractic management included pelvic mobilizations, myofascial therapy, transverse friction massage, and stretching exercises. After 3 visits (2 weeks later), result of neurological evaluation was normal, with no residual numbness over the lateral thigh.

CONCLUSION

In the present case, chiropractic management with standard and applied kinesiology techniques resulted in recovery of meralgia paresthetica symptoms for this patient.

The role of lumbopelvic posture in pelvic floor muscle activation in continent women

This study was undertaken to determine the effect of changing standing lumbopelvic posture on pelvic floor muscle (PFM) activation amplitude and timing and the resultant vaginal manometry values recorded during static and dynamic tasks. Sixteen nulliparous, continent women between the ages of 22 and 41 years performed five tasks (quiet standing, maximal effort cough, Valsalva manoeuvre, maximum voluntary contraction (MVC) of the PFMs, and a load-catching task) in three different standing postures (normal lumbopelvic posture, hyperlordosis and hypolordosis). Electromyographic (EMG) data were recorded from the PFMs bilaterally using a Periform™ vaginal probe coupled to Delsys™ Bagnoli-8 EMG amplifiers. In separate trials, vaginal manometry was obtained using a Peritron™ perineometer. Lumbopelvic angle was recorded simultaneously with EMG and vaginal manometry using an Optotrak™ 3D motion analysis system to ensure that subjects maintained the required posture throughout the three trials of each task. All data were filtered using a moving 100 ms RMS window and peak values were determined for each trial and task. Repeated-measures analyses of variance were performed on the peak PFM EMG, intra-vaginal pressure amplitudes, and lumbopelvic angles as well as activation onset data for the cough and load-catching tasks. There was significantly higher resting PFM activity in all postures in standing as compared to supine, and in the standing position, there was higher resting PFM activity in the hypo-lordotic posture as compared to the normal and hyperlordotic postures. During the MVC, cough, Valsalva, and load-catching tasks, subjects generated significantly more PFM EMG activity when in their habitual posture than when in hyper- or hypo-lordotic postures. Conversely, higher peak vaginal manometry values were generated in the hypo-lordotic posture for all tasks in all cases. These results clearly indicate that changes in lumbopelvic posture influence both the contractility of the PFMs and the amount of vaginal pressure generated during static postures and during dynamic tasks. Lumbopelvic posture does not, however, appear to have a significant effect on the timing of PFM activation during coughing or load-catching tasks.