AACP MUSCULOSKELETAL ROADSHOW

Myofascial Pelvic Pain ©Jennie Longbottom MSc BSc MCSP

MBAcC

“Misdiagnosis is the common cause for patients to seek multiple physicians, to undergo pharmacological, psychological and surgical interventions before referral to physiotherapy.”

Chen & Soong 1997; Lindheim 1999; Stones and Mountfield 2000

Causes

• Rotation dysfunction between T9-T12 (Sahramm 2002)

• Referred neural tension from Thoracic Spine

(Bannister 1998; Grant 2002; Peleg et al 1997)

• Endometriosis(Laufer et al 1997; Walter 2001)

• Biopyschosocial involvement•

T 9

Myofascial meridians

Myers 1988

Clinical Reasoning approach

• “Identify the pain mechanism and the tissue type involved.”

• Identify the synergic muscle activity that may reproduce pain

• Identify pelvic floor muscle dysfunction

• Pelvic floor examination is critical to define the scope of symptoms

Co-existence of Urological Dysfunction

• Stress incontinence• Dyspareunia

– Will indicate a muscle performance impairment• Urge incontinence

– Will indicate neural performance impairment • Organ impairment• Autonomic impairment • Co morbidity of mechanical and non

mechanical pain may be present

What are you looking for?

• Soft tissue differentiation• Pain reproduction from:

– Muscle– Ligament– Contraction– Activity or postural dependent pain

• Stress

Treatment Regime

• Correction of muscle imbalance– Trigger point deactivation

• Re-education of faulty movement patterns

• Education of patient• Therapeutic correction

Structures involved

• Joint impairment• Referred from spine, pelvis & hips• Fascial restrictions• Connective tissue impairment• Muscle impairment• Neurological involvement

Pelvic impairment

• Hypermobility of SIJ • Anterior iliac Torsion• Posterior Iliac Torsion• Sacral rotation• Hypermobility PS• Superior/Inferior glide PS

Muscles Involved • Ilopsoas• Gluteus Medius/Maximus• Tight ITB• External / Internal Obturator • Hamstrings• Gastrocnemius• Piriformis• Abdominal muscles• Adductors/Pectineus

Pubic Pain

• Prevalence of pubic pain in pregnancy in Europe 1 in 36

• Ligamentous laxity:– Osteitis Pubis– Ligamentous rupture– Pelvic dislocation

Borg-Stein J (2005)

Posterior Pelvic pain

• Pain between posterior iliac crests and Gluteal fold especially SI joints

• Diagnosis by positive posterior pain provocation test– Palpation of dorsal sacroiliac ligament shows

tenderness on palpation in patients with peripartum pelvic pain.

• Patrick’s fabere testElden (2005)

Protocol

• Desensitise allodynic tissues• Timed voiding to reduce sensitivity

of bladder wall• Release connective tissue tension in

pelvis• Viscero-somatic and somatovisceral

reflex inhibition• Release trigger points

Muscles Involved

The Adductor Mechanism

Adductor Brevis Adductor Longus

Pectineus

The Abdominal Component

External Oblique Rectus Abdominus

MultifidusIlopsoas

Pyramidalis

Diastases Rectus Abdominus

ILIOPSOAS MYOFASCIAL RELEASE

Lund et al 2006

• Pain sites • 18-35 weeks

gestation• 10 points used• BL 27-54• KI11• CV3

• Innervation• LI4• SP6• Liv2• 2xweekly

Elden et al (2005)• Pelvic girdle pain • 12-31 weeks gestation• 17 points• 10 Local segmental• BL26-54• KI !!• GB 30• SP 12• HJJ L4/5

• 7 Distal • GV 20• LI 4• ST 36• BL 60• 2xweekly x6 weeks• Acupuncture superior

to stabilizing exs alone

Guerreiro da Silva et al (2004)

• LBP / Pelvic Pain• 15-30 weeks gestation• 12 needles• KI 3• SI 3• BL 40, BL 62• TE 5• GB 30, 41• HJJ

• 8-12 Rx over 8 weeks

• Control group paracetamol and hyoscine

• &8% NRS in acupuncture

• 15% in control

Kvorning et al (2004)

• Pelvic and LBP in late pregnancy

• 24-37 weeks gestation

• Liv 3• GV 20 • Bl 60• SI 3

• BL 22-26• Ashi points at ASIS• SI joint• Symphasis Pubis

(CV2) Periosteal pecking

• Control TENS, physiotherapy, SI belt

• 43% acupuncture group

• 9% control

Wedenberg et al (2000)

• LBP and PP• 20-32 weeks

gestation• 2-10 points• Auricular• Bl 26-30• CV2• Ashi points

• 3x weekly x 2 weeks• 2x weekly for 2 weeks• Control physiotherapy• VAS and PDI

decreased significantly in acupuncture group

Research • Highfield ES et al (2006) Adolescent

endometriosis-related pelvic pain treated with acupuncture: two case reports. Journal Alt comp Med: Apr 1 ; 12(3): 317-22

• Wedenberg et al (2000)A prospective RCT comparing acupuncture with physiotherapy for LBP and pelvic pain in pregnancy. Acta Obst & Gynea Scand:79;331-335

• Young G (2006) Interventions for preventing and treating chronic pelvic pain and back pain in pregnancy. Cochrane Library (4)

• acupuncture was rated as giving 'good' or 'excellent' help more frequently than physiotherapy (odds ratio 6.58, 95% confidence intervals 1.0-43.16) but this may reflect the benefit of individual compared with group therapy.

• Both physiotherapy and acupuncture may reduce back and pelvic pain.

• Individual acupuncture sessions were rated as more help than group physiotherapy sessions.

Kim (2005) Acupuncture for pelvic girdle pain in pregnancy. Alternative Therapies in Women's

Health Dec; 7 (12): 93-5 • Comparison of:

– Standard treatment (n = 130) – Standard treatment plus acupuncture (n = 125)– Standard treatment plus stabilizing exercises for pelvic girdle

pain during pregnancy (n = 131) – RCT single-blind con-trolled trial 27 maternity care centres. The

participants (n = 386) were pregnant women with pelvic girdle pain who were treated for six weeks with:

– Assessment: VAS– Concluded that acupuncture and stabilizing exercises

constitute efficient complements to standard treatment for the management of pelvic girdle pain during pregnancy.

– Acupuncture was superior to stabilizing exercises in this study.

Myofascial Pain Research

• Baker P (1998) Musculoskeletal problems in chronic pelvic pain. An Integrated approach. Philadelphia: W.B. Saunders 215-240

• King et al (1991) Musculo-skeletal factors in CPP. J Psychom Obstet Gynecol 12: 87-98