Innovative techniques to optimize clinical results.
Pelvic floor pathology comes in a variety of diagnoses, etiologies, and presentations. (1) Patients are often referred to physical therapy with medical diagnoses such as: chronic pelvic pain syndrome (CPPS), interstitial cystitis, irritable bowel syndrome, endometriosis, dyspareunia, pudendal neuralgia, bowel and urinary incontinence, and chronic prostatitis. (2-4) Symptom presentation is quite varied, but often include bowel, bladder and sexual dysfunctions. That being said, a multidisciplinary approach is obviously crucial to tailor treatment specific to each patient’s pathology, symptomatology, and clinical presentation. (5) Many of these patients have seen a variety of gynecologists, urologists, and gastroenterologists without successful symptom mitigation and are being referred to pelvic health physiotherapy as a last resort. This is unfortunate as a primary contributor to these symptoms is the neuromusculoskeletal system, and who better to treat than rehabilitative clinicians?
A clinical example: Chronic Pelvic Pain Syndrome (CPPS)
Let’s focus this discussion on the patient referred to us with CPPS. Epidemiological data suggest that chronic, widespread, nonspecific musculoskeletal pain is on the rise and has doubled in the past 15 years, affecting approximately one third of the adult population in the United States (6,7), while Zondervan et al. reports that the estimated lifetime occurrence of CPPS is 33%. (8) Naturally, it seems like an appropriate place to begin.
We need to first consider that the term “pelvic pain” can mean many different things to our individual patients. In fact, pelvic pain has been associated with over 70 different diagnoses that often present with overlapping physical, functional and psychological components. (3) This can, no doubt, lead to variability in clinical presentation, so keep that in mind as this “typical patient presentation” can look quite different from patient to patient.
Often, a patient referred to us with CPPS will present with the following symptoms and/or clinical findings: low back, hip, and/or pelvic pain, muscular imbalances in the lumbopelvic and hip complexes, postural asymmetry, impaired muscle coordination, abnormal movement strategies, and bowel, bladder and/or sexual dysfunction. (1-5,9,10)
What does clinical management look like for this patient?
There are going to be varying approaches to how we sequence treatment with this particular patient presentation. Do we start with posture? Do we start with the muscle imbalances? Do we address the pain? One approach isn’t necessarily better than the next and how we decide to treat these dysfunctions will be heavily influenced by our clinical experience and training.
We can also argue that there is, no doubt, conflicting evidence for each and every treatment approach out there. That being said, I am going to provide you with a more global approach as to how I might personally treat this client and not necessarily how to sequence each and every clinical session.
We all know that our clients with a history of chronic pain want to understand why they are experiencing this pain and why other treatment modalities have not worked. Pain is a multiple system output that is activated by the brain based on perceived threat. (7) I have found that by combining patient education, dry needling, manual therapies, and neuromuscular re-education, we can provide quite a powerful treatment approach for pelvic pain. Starting with tactful educational strategies to address the neurophysiology and neurobiology of pain, relating this to the unique individual’s experience, and providing the patient with strategies for sympathetic nervous system "down training" has been a meaningful place to begin. Once we educate the patient properly on why they might be experiencing pain, we can then progress to utilization of dry needling and other manual therapies to assist in further mitigating the pain response and, hopefully, improving the client’s overall level of dysfunction long term.
Why multimodal practice is key.
Patient education can be a very powerful modality, which many clinicians tend to overlook. Research suggests education may help to address the central nervous system upregulation, and may help to retrain the brain in how it is processing input. A study by Lorimer Moseley showed reduced widespread brain activity on functional MRI following pain physiology education, leading us to deduce that a brain that understands how pain is processed is less threatened and the impact on the central nervous system is markedly reduced. (6) Pretty powerful to be able to change pain processing! But it doesn't stop with education, we also need to provide non-threatening input to the tissues.
A large percentage of chronic pain begins when tissue and/or nerves are damaged in the periphery. (11) Manual therapies may help to desensitize the peripheral nervous system and surrounding soft tissues by providing neural input to alter the source of the pain. (11,12) These techniques, whether you’re using joint mobilizations, soft tissue release, myofascial techniques, tool assisted therapies, or any other manual approach, are likely addressing local tissue issues that may be perpetuating chronic pain.
Dry needling is another technique we can utilize to modulate the central and peripheral nervous systems. (12) There are many theories and conflicting evidence surrounding how this actually happens in the body. While the analgesic mechanism of dry needling is still not well known, we have seen more and more evidence that supports the use of this treatment in our practice. Overall, it is thought that dry needling may address hypersensitive neural structures and spinal segments (4), enhance treatment of myofascial pain and trigger points in the pelvic floor and surrounding musculature (12-24), and assist in the facilitation and/or inhibition of abnormal muscle tone and motor recruitment patterns (25).
Dry needling is one of our most effective tools to reset a dysfunctional tissue, providing us with functional change and decreased pain associated with movement. Subsequently, we are then able to facilitate healthier motor recruitment patterns to re-establish functional pain free movement for our clients. The power of the tissue reset that dry needling provides has changed my clinical practice and has also positively impacted and changed the lives of many of my clients. Want to add this tool to your clinical practice? Check out our course offerings with PPHC.
Take Home
Pelvic floor dysfunction is a relevant and common dysfunction that clinicians find their clients are experiencing. These pathologies are very real, very debilitating, but are also very treatable. To begin our treatment approaches we must first identify these symptoms, then employ a multi-faceted and tailored regime specific to each patient. Within those treatments, dry needling can be a powerful tool that we may utilize to address the neuromuscular dysfunction that exists in our tissues which can, in turn, impact the neurophysiologic aspect of pain; however, we cannot forget about our utilization of other therapies to then reinforce our tissue reset and retrain our patients back to optimal function!
To health + wellness for your pelvis,
Kelly
References:
1. Messelink et al. Standardization of Terminology of Pelvic Floor Muscle Function and Dysfunction: Report from the Pelvic Floor Clinical Assessment Group of the International Continence Society. Neurology and Urodynamics. 2005;24:374-380
2. Anderson R, Sawyer T, Wise D, Morey A and Nathanson B. Painful Myofascial Trigger Points and Pain Sites in Men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome. The Journal of Urology. 2009;182:2753-2758
3. Hahn L. Chronic Pelvic Pain in Women. Lakartidningen. 2001;98:1780-5
4. Kotarinos R. Myofascial Pelvic Pain. Curr Pain Headache Rep. 2012;16:433.438
5. Srinivasan A, Kaye J, Moldwin R. Myofascial Dysfunction Associated with Chronic Pelvic Floor Pain: Management Strategies. Current Pain and Headache Reports. 2007;11:359-364
6. Moseley G. Widespread Brain Activity During An Abdominal Task Markedly Reduced After Pain Physiology Eduction: fMRI Evaluation of a Single Patient with Chronic Low Back Pain. Australian Journal of Physiotherapy. 2005;51(1):49-52
7. Moseley G. A Pain Neuromatrix Approach to Patients with Chronic Pain. Manual Therapy. Aug 2003;8(3):130-140
8. Zondervan K et al. Chronic Pelvic Pain in the Community - Symptoms, Investigations and Diagnoses. American Journal of Obstetrics and Gynecology. 2001;184(6):1149-1155
9. Johannes et al. The Prevalence of Chronic Pain in United States Adults. The Journal of Pain. Nov 2010;11(11)1230-1239
10. Strauss A and Dimitrakov J. New Treatments for Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Urology. 2010;7:127-135
11. Baron et al. Peripheral Input and Its Importance for Central Sensitization. Ann Neurol. 2013;74(5):630-6
12. Chou L, Kao M, Lin J. Probably Mechanisms of Needling Therapies for Myofascial Pain Control. Evidence-Based Complimentary and Alternative Medicine. 2012;11
13. Chen J, Chen S, Kuan T, et al. Phentolamine Effect on the Spontaneous Electrical Activity of Active Loci in a Myofascial Trigger Spot of Rabbit Skeletal Muscle. Archives of Physical Medicine and Rehabilitation. 1998;79(7):790-4
14. Cummings T and White A. Needling Therapies in the Management of Myofascial Trigger Point Pain: A Systematic Review. Archives of Physical Medicine and Rehabilitation. 2001;82(7):986-992
15. Gerber L, Shah J, Rosenberger W et al. Dry Needling Alters Triggers Points in the Upper Trapezius Muscle and Reduces Pain in Subjects with Chronic Myofascial Pain. Physical Medicine and Rehabilitation. 2015;7(7):711-718
16. Gunn C, Milbrandt W, Little A et al. Dry Needling of Muscle Motor Points for Chronic Low Back Pain: A Randomized Clinical Trial with Long-Term Follow-Up. Spine. 1980;5(3):279-291
17. Hsieh Y et al. Dry Needling to a Key Myofascial Trigger Point May Reduce Irritability of Satellite MTrPs. American Journal of Physical Medicine and Rehabilitation. 2007;86(5):397-403
18. Lewit K. The Needle Effect in the Relief of Myofascial Pain. Pain. 1979;6(1):83-90
19. Shah J. Uncovering the Biochemical Milieu of Myofascial Trigger Points Using In Vivo Microdialysis. Journal of Musculoskeletal Pain. 2008;16(1-2):17-20
20. Shah J, Danoff J, Desai M et al. Biochemicals Associated with Pain and Inflammation are Elevated in Sites Near to and Remote from Active Myofascial Trigger Points. Archives of Physical Medicine and Rehabilitation. 2008;89(1):16-23
21. Sterling M, Valentin S, Vicenzino B, et al. Dry Needling and Exercise for Chronic Whiplash - A Randomized Controlled Trial. BMC Musculskeletal Disorders. 2009;10:160
22. Tough E, White A, Cummings T, et al. Acupuncture and Dry Needling in the Management of Myofascial Trigger Point Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. European Journal of Pain. 2009;13(1):3-10
23. Tuzun E, Gildir S, Angın E, et al. Effectiveness of Dry Needling Versus a Classical Physiotherapy Program in Patients with Chronic Low-Back Pain: A Single-Blind, Randomized, Controlled Trial. Journal of Physical Therapy Science. 2017;29(9):1502-1509
24. Hong C and Torigoe Y. Electrophysiological Characteristics of Localized Twitch Responses in Responsive Taut Bands of Rabbit Skeletal Muscle Fibers. Journal of Musculoskeletal Pain. 1994;2(2):17-43
25. Puentedura E, Buckingham S, Morton D, et al. Immediate Changes in Resting and Contracted Thickness of Transversus Abdominis After Dry Needling of Lumbar Multifidus in Healthy Participants: A Randomized Controlled Crossover Trial. Journal of Manipulative and Physiological Therapeutics. 2017;40(8):615-623