The Puzzle of Pelvic Pain—A Rehabilitation Framework for Balancing Tissue Dysfunction and Central Sensitization, I: Pain Physiology and Evaluation for the Physical Therapist

Effect of dry needling on pain and central sensitization in women with chronic pelvic pain: A randomized parallel-group controlled clinical trial

Chronic pelvic pain (CPP) is a debilitating problem in women with clear evidence of myofascial dysfunction. It seems that Myofascial trigger points (MTrPs) contribute to the development of central sensitization (CS). This study aimed to investigate the effect of dry needling on pain and CS in women with CPP. Thirty-six women with CPP participated in this randomized controlled clinical trial and randomly assigned into three groups: dry needling group (DNG), placebo needling group (PNG) and control group (CG). The DNG received five sessions of DN using the "static needling", the PNG received non-penetrating method, and the CG did not receive any intervention. Assessment of outcomes including central sensitization inventory (CSI), short-form McGill pain questionnaire (SF-MPQ), electroencephalography (EEG), conditioned pain modulation (CPM), salivary cortisol concentration, 7-item general anxiety disorder scale (GAD-7), pain catastrophizing scale (PCS), and SF-36 questionnaire was performed pre-intervention, post-intervention, and three months post-intervention by a blind examiner. The result showed a significant group-by-time interaction for CSI, SF-MPQ, and PCS. There was a significant decrease in CSI score in post-intervention and three-months post-intervention compare to pre-intervention in the DNG and PNG. SF-MPQ-PPI score in DNG significantly decreased post-intervention. PCS-Total score decreased significantly post-intervention in DNG and PNG. No significant group-by-time interactions were observed for other variables. EEG results showed regional changes in the activity of frequency bands in both eye closed and eye open conditions. It seems that DN can affect central pain processing by removing the source of peripheral nociception. Trial registration: Iranian Registry of Clinical Trials (IRCT20211114053057N1, registered on: December 03, 2021. https://irct.behdasht.gov.ir/search/result?query=IRCT20211114053057N1).

How Might We Screen for Psychological Factors in People With Pelvic Pain? An e-Delphi Study

OBJECTIVE

Persistent pelvic pain (PPP) is a complex condition often influenced by psychological factors that can alter treatment outcomes. These factors are potentially modifiable; however, currently there is no instrument to screen for them. The purpose of this study was to determine: (1) which psychological factors should be screened in individuals with PPP, and (2) the most appropriate statements to represent these psychological factors.

METHODS

The study used a focus group design followed by an electronic-Delphi (e-Delphi) process. A focus group consisting of 8 experts was conducted to determine the relevant psychological factors to screen. These results informed round 1 of the e-Delphi process, consisting of a panel of 14 pain/pelvic pain experts. The e-Delphi process consisted of 3 rounds of online surveys and 2 teleconference discussions to establish consensus on the most appropriate statement to screen for each of the psychological factors.

RESULTS

The focus group identified 13 relevant psychological factors. During the e-Delphi process, relevant screening statements were assessed using a 100-point allocation system. Experts could reword and suggest new statements. Statements were assessed for consensus and stability and were eliminated as the rounds progressed if they met the exclusion criteria. At the termination of round 3, there were 15 statements remaining.

CONCLUSION

The final list of 15 statements will assist clinicians in screening for psychological factors and is an important step for clinicians in providing psychologically informed care to people with PPP. Future research should determine the psychometric properties of the statements to determine their clinical utility as a questionnaire.

IMPACT

This study has refined a list of statements to help screen for psychological factors in individuals with PPP. Developed robustly using an e-Delphi method, this list is an important first step forward for clinicians to provide psychologically informed care to these individuals.

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.

The Role of Physical Therapy in Sexual Health in Men and Women: Evaluation and Treatment

INTRODUCTION

Many conditions of pelvic and sexual dysfunction can be addressed successfully through pelvic floor physical therapy (PFPT) through various manual therapy techniques, neuromuscular reeducation, and behavioral modifications. The field of pelvic rehabilitation, including sexual health, continues to advance to modify these techniques according to a biopsychosocial model.

AIM

To provide an update on peer-reviewed literature on the role of PFPT in the evaluation and treatment of pelvic and sexual dysfunctions in men and women owing to the overactive and the underactive pelvic floor.

METHODS

A literature review to provide an update on the advances of a neuromusculoskeletal approach to PFPT evaluation and treatment.

MAIN OUTCOME MEASURE

The use and advancement of PFPT methods can help in successfully treating pelvic and sexual disorders.

RESULTS

PFPT for pelvic muscle overactivity and underactivity has been proven to be a successful option for pelvic and sexual dysfunction. Understanding the role of the organs, nerves, fascia, and musculoskeletal system in the abdomino-pelvic and lumbo-sacro-hip region and how pelvic floor physical therapists can effectively evaluate and treat pelvic and sexual health. It is important for the treating practitioner to know when to refer to PFPT.

CONCLUSION

Neuromusculoskeletal causes of pelvic floor disorders affect a substantial proportion of men, women, and children and PFPT is a successful and non-invasive option. Pelvic floor examination by healthcare practitioners is essential in identifying when to refer to PFPT. Use of a biopsychosocial model is important for the overall well-being of each patient. Further research is needed. Stein A, Sauder SK, Reale J. The role of physical therapy in sexual health in men and women: Evaluation and treatment. Sex Med Rev 2019;7:46-56.

Physical Therapy in the Treatment of Central Pain Mechanisms for Female Sexual Pain

INTRODUCTION

The complexity of female sexual pain requires an interdisciplinary approach. Physical therapists trained in pelvic health conditions are well positioned to be active members of an interdisciplinary team addressing the assessment and treatment of female sexual pain. Changes within physical therapy practice in the last ten years have resulted in significant utilization of pelvic floor muscle relaxation and manual therapy techniques to address a variety of pelvic pain conditions, including female sexual pain. However, sexual pain is a complex issue giving credence to the necessity of addressing all of the drivers of the pain experience- biological, psychological and social.

AIM

This review aims to reconcile current pain science with a plan for integrating a biopsychosocial approach into the evaluation and subsequent treatment for female sexual pain for physical therapists.

METHODS

A literature review of the important components of skilled physical therapy interventions is presented including the physical examination, pain biology education, cognitive behavioral influences in treatment design, motivational interviewing as an adjunct to empathetic practice, and the integration of non-threatening movement and mindfulness into treatment.

MAIN OUTCOME MEASURE

A single case study is used to demonstrate the biopsychosocial framework utilized in this approach.

RESULTS

Appropriate measures for assessing psychosocial factors are readily available and inform a reasoned approach for physical therapy design that addresses both peripheral and central pain mechanisms. Decades of research support the integration of a biopsychosocial approach in the treatment of complex pain, including female sexual pain.

CONCLUSION

It is reasonable for physical therapists to utilize evidence based strategies such as CBT, pain biology education, Mindfulness Based Stress Reduction (MBSR), yoga and imagery based exercises to address the biopsychosocial components of female sexual pain.