Chronic pelvic pain and dysfunction

Front Cover
Chronic Pelvic Pain and Dysfunction: Practical Physical Medicine
Copyright
Contents
Contributors
Foreword
Acknowledgements
Chapter 1: An introduction to chronic pelvic pain and associated symptoms
	Introduction
	Definitions of chronic pelvic pain syndromes
	Chronic pain
	Pelvic girdle pain and CPP: To separate or combine?
	Connecting PGP with CPP
	Aetiological features of CPP
	Beyond single causes
	Treatment aimed at pathology is only part of the answer
	References
Chapter 2.1: An introduction to the anatomy of pelvic pain
	References
Chapter 2.2: Anatomy and biomechanics of the pelvis
	The anatomy of the sacroiliac joint
		Why did nature create a seemingly flat SIJ?
		What specific adaptations are available to prevent shear in the SIJs?
		Why is the SIJ not perpendicularly orientated to the forces of gravitation?
	Ligaments and their role in self-bracing the pelvis
		Sacrotuberous ligaments
		Long dorsal sacroiliac ligaments
			Anatomical aspects
			Biomechanical aspects
	The role of the thoracolumbar fascia in stabilizing the lumbopelvic area
		Anatomical aspects
			Superficial lamina
		Biomechanical aspects
			Traction to the superficial lamina
			Traction to the deep lamina
	Muscles and self-bracing
		Self-bracing during forward bending
		Self-bracing in unconstrained positions
		Failed self-bracing
	Optimal and non-optimal pelvic girdle stability
	Acknowledgement
	References
Chapter 2.3: Anatomy of the pelvic floor
	Pelvic floor muscles
		The deep PFM: Levator ani muscle
		The superficial PFM and perineal body
	Endopelvic fascia
	Pelvic viscera
		Bladder and urethra
		Prostate
		Vagina and uterus
		Penis, scrotum and testes
		Rectum and anal canal
	Innervation of the pelvic organs and PFM
	References
Chapter 3: Chronic pain mechanisms
	Defining chronic pelvic pain
	Chronic pelvic pain syndrome: The cause
	Chronic pelvic pain syndrome: The mechanisms
	Mechanisms for chronic pelvic pain
	Ongoing peripheral visceral pain mechanisms as a cause of chronic pelvic pain
	Spinal mechanisms of visceral pain and sensitization: Central sensitization (Roza et al. 1998, Giamberardino 2005)
	Visceral hyperalgesia
	Supraspinal modulation of pain perception
	Higher-centre modulation of spinal nociceptive pathways
	Neuromodulation and psychology
	Autonomic nervous system
	Endocrine system
	Genetics and chronic pain
	Clinical paradigms and chronic pelvic pain
	References
Chapter 4: Psychophysiology and pelvic pain
	Introduction
	Psychophysiology in historical perspective
	Modern psychophysiological research
	Prostate and pelvic pain
	Alexithymia and pelvic pain
	Pain catastrophizing and fear-avoidance
	Hypervigilance and fear of movement
	Avoidance of sexual activity
	Defensiveness, emotional denial and repression
	Placebo-nocebo chemistry as psychophysiology
	Effects of physical and sexual abuse
	Somatization
	Acknowledgement
	References
Chapter 5: Gender and chronic pelvic pain
	Introduction
	Gender and pain: The role of sex hormones
		Sex hormones and pain
	Visceral pelvic pain
		Visceral pain
	Pelvic pain from sex-specific internal organs
		Pain from the female reproductive organs
			Primary dysmenorrhoea
			Endometriosis
			Pelvic inflammatory disease
		Pain from the male reproductive organs (See also Chapters 12 & 15)
			Prostatitis/prostatodynia
			Chronic orchialgia
	Pelvic pain from non-sex-specific visceral organs
		Irritable bowel syndrome
		Interstitial cystitis/painful bladder syndrome
	Mixed pelvic pain
		Chronic pelvic pain of mixed origin
		Chronic pelvic pain from viscerovisceral hyperalgesia
	Are women more susceptible than men to chronic pain?
	Conclusion
	References
Chapter 6: Musculoskeletal causes and the contribution of sport to the evolution of chronic lumbopelvic pain
	Introduction
	Assessment of the movement system
	Common postural types (see Kendall et al. 2005, Sahrmann 2002)
	Lumbopelvic cylinder and chronic pelvic pain
	Assessment and rehabilitation of muscles of the lumbopelvic cylinder
		Voluntary activation of TrA independently from other trunk muscles (Richardson et al. 1999)
	Assessment and rehabilitation of muscles of the lumbopelvic cylinder
		Voluntary activation of pelvic floor muscles (Laycock
		Voluntary activation of deep segmental lumbar multifidus (Richardson et al. 1999)
		Voluntary activation of the posterior fasciculii of psoas (Gibbons et al. 2002)
		Integration of voluntary activation of the lumbopelvic cylinder into function
	The neural system and chronic pelvic pain
	Sporting activities and chronic pelvic pain
		The effect of aerobic exercise on chronic pelvic pain
		Specific groin injuries
		Ligament and muscle strain
		Acetabular tears and impingements of the hip
		Osteitis pubis
		Athletic pubalgia or sports hernias
		Stress fractures
		Nerve compression
		Cycling and genitourinary symptoms in men and women
		Symptoms
		Potential mechanisms
		Therapeutic options regarding adjustable bicycle factors
			Saddle design
			Posture and type of bike
			Saddle width
			Saddle padding
		Conclusions
		Running
		Football
		Ice hockey
		Sports involving repetitive flexion of the hip
	Case study 6.1
	Case study 6.2
	References
Chapter 7: The role of clinical reasoning in the differential diagnosis and management of chronic pelvic pain
	Introduction
	Evidence-based practice: Where did it come from? Where is it going?
	Understanding pain: What do we need to know?
		What causes pain? Searching for the pain driver
	Classifying pain
		Timelines and mechanism of injury
		Classification by pain mechanisms
		Classification and clinical prediction rules: Are we searching for the holy grail?
	It's about more than pain - Integrated systems for optimal health
	The Integrated Systems Model for disability and pain: A framework for understanding the whole person and their problem
		Underlying constructs of the model
		Components of the model: The Clinical Puzzle - A tool for clinical reasoning and developing clinical expertise
			The person in the middle of the puzzle
			Strategies for function and performance
			Articular, myofascial, neural, visceral systems
	Case study 7.1
		Kristi's story
			Strategies for function and performance
				Standing posture
				One leg standing
				Active straight leg raise
				Curl-up task
				Clinical reasoning at this point
				Articular system analysis
				Neural system analysis
				Myofascial system analysis
				Clinical impression derived from hypothesis development, reflection and interpretive reasoning
		Two days postpartum
			Strategies for function and performance, myofascial and neural system analysis
				Standing posture
				One leg standing, active straight leg raise and curl-up tasks
			Clinical reasoning and early postpartum management
		Six weeks postpartum
			Strategies for function and performance
				Standing posture
				One leg standing and active straight leg raise tasks
				Articular and neural system analysis
				Curl-up task and myofascial system analysis
			Clinical reasoning and management
		Twelve weeks postpartum
		Fourteen weeks postpartum
			Strategies for function and performance
				One leg standing and active straight leg raise
				Curl-up task and myofascial system analysis
				Neural system analysis
			Clinical reasoning and management
		Case conclusion
	Summary
	References
Chapter 8.1: Multispeciality and multidisciplinary practice...
	Multispeciality and multidisciplinary practice (Baranowski et al. 2008)
	The medical teams
	The multispeciality clinic
	The multidisciplinary team and clinic
	The role of the pain medicine consultant
	The role of the psychologist
	The role of the clinical nurse specialist or nurse consultant (Cambitzi & Baranowski 2009)
	The role of the physiotherapist
	The pain management programme
	Summary
	References
Chapter 8.2: Interdisciplinary management of chronic pelvic pain...
	Introduction
	Team management
	Organic pathology intervention
	Cognitive behavioural therapy
	Manual physical therapy intervention
		Altered neurodynamics
	Lifestyle modifications and home exercise programmes
	Pharmacological therapy
		Simple analgesics
		Neuropathic analgesics
			Anticonvulsants
		N-methyl-D-aspartate antagonists
		Opioids
	Trigger point injection therapy
	Nerve blocks
	Botulinum toxin therapy
	Pulsed radiofrequency
	Neuromodulation
		Sacral neuromodulation
		Posterior tibial nerve stimulation
		Chronic/continuous pudendal nerve stimulation
	Multimodal treatment algorithm
	Reasons for poor treatment tolerance
	Modifying manual treatment
	Non-responding symptoms
	References
Chapter 8.3: Chronic pelvic pain and nutrition
	Introduction
	Inflammation
	Dietary anti-inflammatory strategies
	Antioxidants and anti-inflammatory nutrients
	Anti-inflammatory effects of omega-3 and -6 oils
	Vitamin D and pelvic floor disorders in women
	CPP/endometriosis and diet
	Dysmenorrhoea: Studies and meta-analyses
	Painful bladder syndrome
	Vulvar vestibulitis syndrome and interstitial cystitis
	Irritable bowel syndrome and diet
		Peppermint oil
		Turmeric (curcumin)
		Probiotics
	Acknowledgement
	References
Chapter 9: Breathing and chronic pelvic pain...
	Introduction
		The lumbopelvic cylinder: Functional and structural connections
		The retroperitoneal space
		Interaction of CPP, pelvic girdle pain and breathing pattern disorders aetiological features
		Postural and breathing patterns as aetiological features
	Pelvic girdle pain: Respiratory connections
		Gut connections to CPP and to respiration
		An integrated system
	Varieties of breathing pattern disorder
		Breathing pattern disorders - The postural connection
			Examples
		Repercussions of breathing pattern disorders
		BPD and hyperventilation: Physical features - Implications for rehabilitation
		Viscerosomatic effects
		'Biologically unsustainable patterns' (Garland 1994)
		Myofascial trigger points
	Breathing rehabilitation assessment and interventions (Chaitow et al. 2002)
		Functional examination: Identifying the locus of motion
			HiLo test
			Manual assessment of respiratory motion
		Current thoracic excursion
	Breath-holding tests
	Teaching control of breathing
	CO2 regulation study
		The Mensendieck approach
	Research on breathing as a pain intervention
		Stress and breathing
		Conditioned breathing responses
		Manual treatment of selected key structures associated with respiration
	Connective tissue manipulation
	Trigger point deactivation and slow stretching (Travell & Simons 1999, Cox 2005)
		Diaphragm
			NMT for diaphragm (Chaitow 2007, Chaitow & DeLany 2008)
			PRT for diaphragm
		Intercostals
			NMT for the intercostal muscles
		Psoas
			MET for psoas (Grieve 1994, Chaitow 2006)
		Quadratus lumborum
			PRT for quadratus lumborum
		Scalenes (and other upper fixators of the shoulder/accessory breathing muscles)
			PRT for scalenes
		Thoracic and costal mobilization
			MET for thoracic spine
	Scar tissue release
	Myofascial release (myofascial induction)
		Study
	Conclusions
	References
Chapter 10: Biofeedback in the diagnosis and treatment of chronic essential pelvic pain disorders
	Pain, relaxation and biofeedback
		SEMG biofeedback
		Skin temperature
		Galvanic skin response
		Breathing
	Research applications to pelvic pain problems
		Hand temperature and pelvic pain
		Muscle biofeedback and pelvic pain
		Intrapelvic SEMG in the treatment of functional chronic urogenital, gastrointestinal and sexual pain and dysfunction
			Biofeedback meets evidence-based medicine: The Glazer Protocol
				Applications
				Patient selection
				Assessment with the Glazer Protocol
			Levels of interpretation and applications of SEMG evaluation data include both empirical and pathophysiological perspectives
				Empirical
				Physiological
	Developing evidence-based biofeedback applications for pelvic pain
	Selected ongoing international collaborative research
	Research summary
		Summary of Medline 'biofeedback' 'pelvic pain' literature search
	Case study 10.1
		Health concerns
		Hospital/surgery/major illness
		Medications currently taking
		Supplements
		Allergies
		Family history
		Systems review
		Psychometrics: MMPI-2
		Medical examination
		Patient narrative
		Sexual evaluation
		Intrapelvic SEMG evaluation
		History and data review and integration with treatment(s) prescribed
			Summary of findings
			Interpretation of findings
			Treatment
		Outcomes
			Medical
			Psychological, psychosexual
			Social, marital, occupational
			Substance use
			Treatment compliance
	References
	Websites
Chapter 11.1: Soft tissue manipulation approaches to chronic pelvic pain (external)
	Introduction
	Local muscle dysfunction: Muscle trigger points
		Trigger points and chronic pelvic pain
		Why is inactivation of trigger points in chronic pelvic pain important?
		Best evidence of soft tissue interventions for muscle trigger points
	Application of soft tissue interventions for trigger points
		Compression interventions
		Static compression of piriformis/external obturator muscle trigger points
		Static compression of pectineus muscle trigger points
		Intermittent compression of pelvic floor muscle trigger points
		Compression and contraction of gluteus maximus muscle trigger points
		Stretching compression of iliopsoas muscle trigger points
		Massage
			Transverse massage of quadratus lumborum muscle trigger points
		Stretching longitudinal massage of adductor muscle trigger points
		Muscle energy interventions
		Muscle energy technique of quadratus lumborum muscle trigger points
	Neuromuscular technique connective tissue approaches for chronic pelvic pain
		Longitudinal stroke of abdominal wall muscle trigger points
		Stretching stroke of gluteus medius muscle trigger points
		Dynamic longitudinal stroke of thoracolumbar extensor muscle trigger points
	Myofascial induction interventions
		Introduction to fascial tissue
		Fascial continuity model
			Which functional model may link all these requirements?
		Theoretical aspects for the treatment of myofascial dysfunction syndrome
			Mechanics of the myofascial dysfunction syndrome
			Neurophysiological mechanisms for releasing the restrictions of the fascial tissue
		Therapeutic strategies applied to the myofascial induction process
			General observations related to the therapeutic process
			Definition of myofascial induction process
			Bases for clinical applications
				General observations (Pilat 2003, 2010)
				Clinical procedure principles (Pilat 2003, 2007a, 2009, 2010)
			Examples of clinical applications
				Transverse plane induction of the pelvic region (Figure 11.1.36)
				Lumbosacral induction
				Induction of the pubic region
				Cross-hand induction of the lumbar spine (Figure 11.1.40)
				Cross-hand induction of the abdominal fascia (Figure 11.1.41)
				Lower induction of the thoracolumbar fascia (Figure 11.1.42)
				Cross-hand induction of the thoracolumbar and gluteal fascia (Figure 11.1.43)
				Quadratus lumborum fascia induction (Figure 11.1.44)
				Paravertebral muscles fascia induction (Figure 11.1.45)
	References
Chapter 11.2: Connective tissue and the pudendal nerve in chronic pelvic pain
	Connective tissue dysfunction in chronic pelvic pain
	Mechanisms of development of subcutaneous panniculosis
	Viscerosomatic reflex
	Superficial to muscles with myofascial trigger points
	Dermatomes of inflamed neural structures
	Superficial to areas of joint dysfunction
	Connective tissue restrictions and altered neural dynamics
	Efficacy of connective tissue mobilization
	Connective tissue manipulation
		Evaluation
		Treatment
		Patient response
		Tissue response
		Special considerations
		Goals
		Contraindications (Goats & Keir 1991)
	The pudendal nerve in chronic pelvic pain
	Pudendal neuralgia
	Pudendal nerve entrapment
	Possible consequences of pudendal neuralgia
		Symptoms
		Evaluation
		Treatment
			Neural mobilization
			Bridging
			Prone with hip internal rotation
		Clinical response
		Patient response
		Home exercise programme
		Special considerations
	Case study 11.2.1
	References
Chapter 12: Evaluation and pelvic floor management of urologic chronic pelvic pain syndromes
	Introduction
	Urologic diagnostic evaluation
		Prostate pain syndrome
			Medical history
			Physical examination
			Imaging of the prostate in chronic prostatitis
			Cystoscopy
			Urodynamics
		Isolated male orchalgia (pain in the testicles)
		Pudendal nerve entrapment (pudendal neuralgia)
		Bladder pain syndrome
			Medical assessment
	Neuromuscular treatment
		Neuromuscular basis for therapy
			Progress of discovery and understanding of chronic pain syndromes and myofascial trigger points
		Wise-Anderson Stanford Protocol
			Painful TrPs, areas of restriction and associated pain location
		The personal therapeutic wand for chronic pelvic pain
		Paradoxical relaxation
	References
Chapter 13: Practical anatomy, examination, palpation and manual therapy release techniques for the pelvic floor
	Introduction
	Female practical anatomy
		Introduction
		Planes of examination
		Practical anatomy on the vertical clock - External perineal
		Practical anatomy on the vertical clock - Internal vaginal
		Practical anatomy on the vertical clock - Internal anal
		Practical anatomy on the horizontal clock - Internal vaginal
	Practical anatomy of the male pelvic floor
		Introduction
		Practical anatomy on the vertical clock - External perineal
		Practical anatomy on the vertical clock - Internal anal
		Practical anatomy on the vertical clock - Internal rectal
		Practical anatomy on the horizontal clock - Internal rectal
	Direction-specific manual therapy of the pelvic floor
		Introduction
		Techniques
		Manual techniques on the vertical plane
			Superficial transverse perineii
			Bulbospongiosus
			Ischiocavernosus
			Anterior to posterior levator ani stretch
			Arcus tendineus fascia pelvis
			Urethra
		External anal sphincter
		Manual techniques crossing over vertical to horizontal plane
			Puborectalis
			Puboanalis
			Tendinous arch of levator ani
		Manual techniques on the horizontal plane
			Posterior fibres of puborectalis and pubococcygeus
			Iliococcygeus and the levator plate
			Ischiococcygeus
			Obturator internus
	Direction-specific breathing release
		Introduction
		Sniff, flop and drop technique
			Abdominal palpation
			Sniff
			Flop
			Drop
			Sniff, flop and drop
			Pelvic floor contraction
			Pelvic floor contraction to drop or flop and drop or sniff, flop and drop
			Transversus abdominis and pelvic floor contraction
			Transversus abdominis and pelvic floor contraction to flop and drop or sniff, flop and drop or with breathing to sniff, flop an
		Home programme
	Further techniques to maximize release
	References
Chapter 14: Patients with pelvic girdle pain...
	Introduction
	Biomechanical model
		Osteopathic manipulative treatment options
	Respiratory-circulatory model
	Neurological model
	Metabolic energy model
	Behavioural model
	Case study 14.1: Male
	Case study 14.2: Female
	Home exercise programme
	Exercise regimens and therapeutic options
	Conclusion
	References
Chapter 15: Intramuscular manual therapy...
	Introduction
	Acupuncture
	Trigger points
	Sham needling
	Evidence of intramuscular manual therapy
	General guidelines
	Low back and hip muscles
		Quadratus lumborum muscle
			Needling technique
			Precautions
		Iliocostalis thoracis muscle
			Needling technique
			Precautions
		Iliocostalis lumborum muscle
			Needling technique
			Precautions
		Semispinalis/multifidus/rotatory muscle (deep)
			Needling technique
			Precautions
		Gluteus maximus muscle
			Needling technique
			Precautions
		Gluteus medius and minimus muscles
			Needling technique
			Precautions
		Piriformis muscle
			Needling technique
			Precautions
		Obturator internus muscle
			Needling technique for the medial part
			Precautions
	Adductor muscles
		Adductor longus/brevis muscle
			Needling technique
			Precautions
		Adductor magnus muscle
			Needling technique
			Precautions
		Pectineus muscle
			Needling technique
			Precautions
	Abdominal muscles
		External oblique, internal oblique, transverse abdominus, rectus abdominis muscles (Figure 15.13)
			Needling technique
			Precautions
		Pyramidalis muscle
			Needling technique
			Precautions
	Hip flexors
		Iliacus muscle
			Needling technique
			Precautions
		Psoas major/minor muscle
			Needling technique
			Precautions
	Pelvic floor (perineal) muscles
		Bulbospongiosus muscle
			Needling technique: Female
			Precautions
		Ischiocavernosus muscle
			Needling technique
			Precaution
		Transverse perineal muscle
			Needling technique
			Precaution
	References
Chapter 16: Electrotherapy and hydrotherapy in chronic pelvic pain
	Introduction
	Goals of hydrotherapy and electrotherapy treatment in chronic pelvic pain
	Modalities
	Electrotherapy
		Electrogalvanic and iontophoresis
		Mechanism of action and physiological effects
		Safety and contraindications
		Galvanic current and levator ani syndrome
		Galvanic iontophoresis
		Additional naturopathic indications
	Low-voltage electrical stimulation
		Mechanism of action and physiological effects
		Safety and contraindications
		Indications
		Intravaginal electrical stimulation in chronic pelvic pain
	Transcutaneous electrical nerve stimulation
		TENS in the symptomatic management of chronic pelvic pain
	Electroacupuncture
		Electroacupuncture relieves pain in chronic prostatitis/chronic pelvic pain
	Percutaneous tibial nerve stimulation
		Posterior tibial nerve stimulation in chronic prostatitis/chronic pelvic pain
	Magnetic and pulsed electromagnetic therapy
		Indications
		Magnetic therapy for stress incontinence
	Diathermy and inductothermy
		Mechanism of action of shortwave diathermy
		Thermal effects
		Athermal effects
		Safety and contraindications
		Diathermy indications
	Pulsed short-wave indications
	Ultrasound
		Safety and contraindications
		Indications
	Low-level laser therapy
		Mechanism of action and physiological effects
		Safety and contraindications
		Indications
	Hydrotherapy
		History of hydrotherapy
		Selected clinical hydrotherapy research
	Balneotherapy and chronic pelvic pain
		Chronic pelvic pain symptoms and their relationship to body temperature perception
		Balneotherapy with antibiotics in the management of acute adnexitis and salpingitis
		Brine electrophoresis in acute inflammation of female genitalia
		Vaginal Irrigations with arsenical-ferruginous water in chronic vaginitis and vulvovaginal dystrophy
		Spa therapy and pelvic inflammatory diseases
	Case study 16.1
		Constitutional hydrotherapy method
	References
Appendix: Clinical outcomemeasurement tools
	The Stanford Pelvic Pain Symptom Score (PPSS) for men (Stanford)
	NIH-Chronic Prostatitis Symptom Index (NIH-CPSI)
	Female questionnaire
	Female Sexual Function Index (FSFI)
		FSFI scoring appendix
		FSFI domain scores and full scale score
	Female Sexual Distress Scale
	Vulvar pain functional questionnaire (V-Q)
	Nijmegen questionnaire
	The self-evaluation of breathing questionnaire
	Description of pelvic girdle pain tests (Vleeming et al. 2008)
		Active straight leg raise test
		Gaenslen's test
		Long dorsal sacroiliac ligament (LDL) test
			The LDL test in postpartum women
			The LDL test in pregnant women
		Pain provocation of the symphysis by modified Trendelenburg's test
		Patrick's Faber test
		Posterior pelvic pain provocation test
		Symphysis pain palpation test
	References
Index