The Effectiveness of Manual Therapy on Chronic Pelvic Pain ... file• Thiele Massage: massage from...
Transcript of The Effectiveness of Manual Therapy on Chronic Pelvic Pain ... file• Thiele Massage: massage from...
The Effectiveness of Manual
Therapy on Chronic Pelvic Pain:
An Evidence-Based Review
Jessica Manley, DPTc
PT 910 Evidence-Based Practice
Spring 2012
The Roles of the Pelvic Floor
Pelvic floor
function
Support for viscera
Spinal stability
Bowel and bladder function
Sexual function
Respiration
Gentilcore-Saulnier et al. 2010, Fritsch et al. 2011
CPP
Pain in the pelvis or lower abdomen
Pain with sex Pain with
urination/defecation
Bowel
and bladder
dysfunction
Sexual
dysfunction
Anxiety
and
depression Anderson et al. 2011,
FitzGerald et al. 2009, Heyman et al. 2006,
Montenegro et al. 2010, Maigne et al. 2006,
Oyama et al. 2004, Figuers et al. 2010
Significance of CPP
Prevalence: 14.7% - 25% women and men
60-95% women and men with refractory CPP
$881 million to $2 billion per year in the US
Alappattu 2011, Stones et al. 2010, Montenegro 2007, Mathias et al. 1996, Tu et al. 2005
Causes of CPP
CPP Trauma
Visceral disease
Visceral pain
Mechanical abnormalities
Chronic holding patterns
Repetitive minor trauma
Pain anxiety
Alappattu 2011, Hoffman 2011, Anderson 2002, Gerwin 2002, Jarrell 2008, Wu et al. 2009
Current Treatment of CPP
Surgery
Laparoscopy
Laparotomy
Coccygectomy
Pharmacology
Hormone therapy
Tricyclic Antidepressants
SSRIs
Local injection
Botox injection
Psychotherapy
Psychotherapy
Writing in a diary
Manual Therapy
Static magnetic therapy
PFM manual therapy?
Roth 2011, Stones et al. 2010, Butrick 2009, Patijn et al. 2010
The CPP Cycle
Hypertonic PFM
Myofascial trigger points
Prevents normal resting tone
PFM dysfunction
Pain anxiety
Sustained muscle activity
Weiss 2001, Montenegro et al. 2008, Chaitow 2007
Relevance to PT
PT
Test and measure
incontinence
Toileting position
Muscle performance
of PFM
Muscle length of
PFM
Myofascial trigger point
release (MFR)
Pauls and Shelly, 1999
PFM Manual Therapy
• PFM Manual Therapy: Compression, contract/relax stretching and STM of myofascial trigger points
• Abdominal wall, back, buttocks, thighs, and PFM transrectally or transvaginally
• Thiele Massage: massage from origin to insertion along the direction of the PFM
Weiss 2001 Butrick 2009
Gap in Literature
No current reviews on manual therapy for
the treatment of men and women with CPP
Little guidance to PTs on effective treatment for these symptoms
Purposes
• Is manual therapy effective at reducing pain for men and women with CPP symptoms?
• This is a foreground question.
Primary Purpose
• Is manual therapy more effective than a control or comparison group at reducing pain for men and women with CPP symptoms?
Secondary Purpose
PICO
P
• Acyclic
• Inflammatory or non-inflammatory pelvic pain
• Lower abdominal pain
• Urogenital pain
• > 1 month
• Not associated with pregnancy
I
• PFM manual therapy
• Thiele Massage
C
• Control
• General, non-specific massage
• Counseling
• Short-form wave therapy (magnetic)
O
• Visual Analog Scale (VAS) for pain
Hypotheses
• Manual therapy is not effective in reducing pain in patients with CPP
First Null Hypothesis:
• Manual therapy is an effective treatment for reducing pain for patients with CPP
First Alternative Hypothesis:
• Manual therapy has no effect on pain reduction when compared to a control or comparison group
Second Null Hypothesis:
• Manual therapy has an effect on pain reduction when compared to a control or comparison group
Second Alternative Hypothesis:
Expected Findings
10-20 articles on manual therapy for CPP
Statistically significant reduction in pain with manual therapy interventions
Statistically significant difference in pain with manual therapy interventions when compared to control or comparison groups
Methods: Criteria
Inclusion Criteria
• PFM Manual therapy
• Outcome measurement of pain with the visual analog scale (VAS)
• English
• Human studies
Exclusion Criteria
• Incorporation of other therapies (chiropractic manipulation, drug therapy, surgery, dry needling)
• Perinatal subjects
• Case reports
Methods
Databases searched
• PubMed
• Cochrane Library
• CINAHL
Search terms
• Thiele massage, physiotherapy, manual therapy, physical therapy, trigger point, or myofascial and coccydynia, perineal, pudendal neuralgia, prostatitis, chronic pelvic pain, pelvic floor, pelvic pain, levator ani, interstitial cystitis, coccygodynia, or sexual dysfunction and pain.
Methods: Statistics
Analysis of reduction in pain via VAS:
• Single group effect size
• Two-group effect size
• Q statistic with inverse variance for weighting
• 95% confidence intervals
Results: Primary Articles
Author, Year Type of Study Level of
Evidence
FitzGerald, 2009 Single-Blind RCT 2b
Maigne, 2006 Randomized Case Control 3b
Heyman, 2006 Randomized Case Control 3b
Anderson, 2011 Case Series 4
Oyama, 2004 Case Series 4
Montenegro, 2010 Case Series 4
Figuers, 2010 Retrospective Case Series 4
Results: Population
Study Patient
Population Age N Diagnosis Duration
FitzGerald, 2009 Females,
Males 43 44
IC/PBS
CP/CPPS <3 years
Maigne, 2006 Females,
Males 45 100 Coccygodynia 13 months
Heyman, 2006 Females 34 44 CPP 29 months
Anderson, 2011 Males 48 116 CP/Orchialgia 4.8 years
Oyama, 2004 Females 42 13 IC 5-14 years
Montenegro, 2010 Females 36 6 CPP >6 months
Figuers, 2010 Females 52 5 CPP 13 years
Results: Population
Patient Characteristic Average Across Studies
Males 45%
Female 55%
Age 42.9 years
Symptom Duration Range 6 months to 14 years
Results: Intervention Study Intervention
Frequency/Duratio
n Follow Up
FitzGerald,
2009
Manual stretching PFM,
MFR of PFM 10 visits, 30-60 mins 12 weeks
Maigne, 2006 Manual stretching PFM 3 visits, 5 mins 12 weeks
Heyman,
2006 Manual stretching PFM 2 visits, 5 mins 4 weeks
Anderson,
2011 MFR to PFM 5 visits, 60 mins 4-6 weeks
Oyama, 2004 Thiele massage 10 visits, 5 mins 6 months
Montenegro,
2010 Thiele massage 4 visits, 5 mins 5-7 weeks
Figuers, 2010 MFR to PFM 3-15 visits 4 weeks
Single Group Effect Size for Pain VAS
Q Statistic: 35.67
-1.28 (-1.93, -0.63)
Random Effects
Model
Statistically
Significant!
Two Group Effect Size for Pain VAS
Q Statistic: 14.28
-0.72 (-1.44, 0.004)
Random Effects
Model
Not statistically
significant
Discussion
Able to reject first null hypothesis!
• Manual therapy is effective
• Effect size is large
• Clinically crucial effect
Cohen 1988
Discussion
Unable to reject second null hypothesis
• Manual therapy is not statistically effective as an intervention when compared to control groups
Clinical Significance
• Change in VAS: Decreased by 2.56 points
Single group effect size
• Change in VAS: Difference between groups of 1.77 points
Two group effect size
• 1 point change on 0-10 scale
MCID in endometriosis
Gerlinger et al. 2010
Two Group Effect Size for Pain VAS
Q Statistic: 14.28
-0.72 (-1.44, 0.004)
Random Effects
Model
Not statistically
significant
Current Treatment of CPP
Surgery
Laparoscopy
Laparotomy
Coccygectomy
Pharmacology
Hormone therapy
Tricyclic Antidepressants
SSRIs
Local injection
Botox injection
Psychotherapy
Psychotherapy
Writing in a diary
Manual Therapy
Static magnetic therapy
PFM manual therapy
Roth 2011, Stones et al. 2010, Butrick 2009, Patijn et al. 2010
Harm/Adverse Events
4 articles mentioned adverse events
• Increase in pain from manual therapy
Potential harm of other interventions vs. manual therapy
• Surgical complications
• Medication side effects
Cost
None of the articles specifically address cost
No direct cost increase
• Training for PTs in PFM manual therapy
• Feasibility at a clinical site
Improvement with brief duration of treatment
• 4 of 8 studies used 5 min treatment sessions
Implications for Clinical Practice
Address this issue!
• 70% of women diagnosed with endometriosis report that at least 1 physician has claimed their symptoms were due to psychological disturbance
What specifically should YOU do?
• Ask patients about pain in this area
• Possible questionnaires: McGill Questionnaire
• Refer as necessary!
Roth 2011, Stones et al. 2010, Montenegro 2007
Limitations
Articles in English available to author
High Q statistic, heterogeneity in articles
• Different manual therapy techniques
• Different diagnoses
Lack of functional outcomes
Pathogenesis of CPP is poorly understood
Future Work
More studies on PFM manual therapy
• CPP diagnosis
• Functional outcomes
• Intervention frequency/duration
Thank You!
• Amy Selinger, PT, DPT, OCS
• Jeannette Lee, PT, PhD
• Diane Allen, PT, PhD
• Brianna Pickering, DPTc
• Justin Trumbull, DPTc
• USCF/SFSU Faculty
• UCSF/SFSU Class of 2012
References 1. Gentilcore-Saulnier E, McLean L, Goldfinger C, Pukall CF, Chamberlain S. Pelvic floor muscle assessment outcomes in women with and without
provoked vestibulodynia and the impact of a physical therapy program. J Sex Med. 2010;7(2 Pt 2):1003-22. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/20059663. Accessed January 5, 2012.
2. Fritsch H, Zwierzina M, Riss P. Accuracy of concepts in female pelvic floor anatomy: facts and myths! World J Urol. 2011. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/22002833. Accessed January 5, 2012.
3. Anderson RU, Wise D, Sawyer T, Glowe P, Orenberg EK. 6-day intensive treatment protocol for refractory chronic prostatitis/chronic pelvic pain
syndrome using myofascial release and paradoxical relaxation training. J Urol. 2011;185(4):1294-9. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/21334027. Accessed November 18, 2011.
4. FitzGerald MP, Anderson RU, Potts J, et al. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological
chronic pelvic pain syndromes. J Urol. 2009;182(2):570-80. Available at:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2872169&tool=pmcentrez&rendertype=abstract. Accessed December 3, 2011.
5. Heyman J, Ohrvik J, Leppert J. Distension of painful structures in the treatment for chronic pelvic pain in women. Obstet Gynecol. 2006;85(5):599-603.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/16752240. Accessed January 4, 2012.
6. Montenegro MLLDS, Mateus-Vasconcelos EC, Candido dos Reis FJ, et al. Thiele massage as a therapeutic option for women with chronic pelvic pain
caused by tenderness of pelvic floor muscles. J Eval Clin Pract. 2010;16(5):981-2. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20590980.
Accessed January 4, 2012.
7. Maigne J-Y, Chatellier G, Faou ML, Archambeau M. The treatment of chronic coccydynia with intrarectal manipulation: a randomized controlled
study. Spine. 2006;31(18):E621-7. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16915077.
8. Figuers CC, Amundsen CL, Weidner AC, Hendricks CK, Holladay CL. Physical Therapist Interventions for Voiding Dysfunction and Pelvic Pain: A
Retrospective Case Series. Phys Ther. 2010;34(2):40-44.
9. Oyama I a, Rejba A, Lukban JC, et al. Modified Thiele massage as therapeutic intervention for female patients with interstitial cystitis and high-tone
pelvic floor dysfunction. Urology. 2004;64(5):862-5. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15533464. Accessed October 12, 2011.
10. Haugstad GK, Haugstad TS, Kirste UM, et al. Mensendieck somatocognitive therapy as treatment approach to chronic pelvic pain: results of a
randomized controlled intervention study. Am J Obstet Gynecol. 2006;194(5):1303-10. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16647914.
Accessed September 26, 2011.
11. Haugstad GK, Haugstad TS, Kirste UM, et al. Continuing improvement of chronic pelvic pain in women after short-term Mensendieck somatocognitive
therapy: results of a 1-year follow-up study. Am J Obstet Gynecol. 2008;199(6):615.e1-8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18845283.
Accessed October 2, 2011.
12. Alappattu MJ, Bishop MD. Psychological factors in chronic pelvic pain in women: relevance and application of the fear-avoidance model of pain. Phys
Ther. 2011;91(10):1542-50. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3185223&tool=pmcentrez&rendertype=abstract.
Accessed April 15, 2012.
References 13. Hoffman D. Understanding multisymptom presentations in chronic pelvic pain: the inter-relationships between the viscera and myofascial pelvic floor
dysfunction. Curr Pain Headache R. 2011;15(5):343-6. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21739128. Accessed March 8, 2012.
14. Gerwin RD. Myofascial and Visceral Pain Syndromes : Visceral-Somatic Pain Representations. Imprint. 2002;10(1):165-175.
15. Butrick CW. Pelvic floor hypertonic disorders: identification and management. Obstet Gynecol Clin North Am. 2009;36(3):707-22.
16. Patijn J, Janssen M, Hayek S, et al. 14. Coccygodynia. Pain Practice. 2010;10(6):554-9. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20825565.
17. Jarrell J. Gynecological pain, endometriosis, visceral disease, and the viscero-somatic connection. J Musculoskelet Pain. 2008;16(1-2):21-27.
18. Travell JG, Simons DG, Simons LS. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2. Lippincott Williams & Wilkins; 1998.
19. Chaitow L. Chronic pelvic pain: Pelvic floor problems, sacroiliac dysfunction and the trigger point connection. J Bodywork Mov Ther. 2007;11:327-339.
20. Gottsch HP, Yang CC, Berger RE. A review of botulinum toxin use for chronic pelvic pain syndrome. Curr Urol Rep. 2010;11(4):265-70.
21. Stones W, Cheong Y, Howard F, Singh S. Interventions for treating chronic pelvic pain in women ( Review ). Cochrane Db Syst Rev. 2010;(11).
22. Tu FF, As-Sanie S, Steege JF. Musculoskeletal Causes of Chronic Pelvic Pain: A Systematic Review of Existing Therapies: Part II*. Obstet Gynecol Surv.
2005;60(7):474-483.
23. Phillips B, Ball C, Sackett D, et al. Oxford Centre for Evidence-based Medicine Levels of Evidence. University of Oxford. 2009;(November 1998):4-5.
Available at: http://www.cebm.net/index.aspx?o=1025.
24. Van Alstyne LS, Harrington KL, Haskvitz EM. Physical therapist management of chronic prostatitis/chronic pelvic pain syndrome. Phys Ther.
2010;90(12):1795-1806. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22211156.
25. Montenegro MLLS, Vasconcelos ECLM, Candido Dos Reis FJ, Nogueira a a, Poli-Neto OB. Physical therapy in the management of women with
chronic pelvic pain. Int J Clin Prac. 2008;62(2):263-9.
26. Pauls J, Shelly E. Applying the Guide to Physical Therapist Practice to women's health physical therapy. Journal of the Section on Women's Health.
1999;23(3):8-12.
27. Anderson RU, Wise D, Sawyer T, Chan C a. Sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: improvement after
trigger point release and paradoxical relaxation training. J Urol. 2006;176(4 Pt 1):1534-8; discussion 1538-9. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/16952676. Accessed January 6, 2012.
28. Weiss JM. Pelvic floor myofascial trigger points: Manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. 2001;166(6):2226-
2231. Available at: http://linkinghub.elsevier.com/retrieve/pii/S0022534705655395. Accessed January 22, 2012.
29. Dommerholt J, Bron C, Franssen J. Myofascial Trigger Points: An Evidence-Informed Review. J Man Manip Ther. 2006;14(4):203-221.
30. Roth RS, Punch M, Bachman JE. Psychological factors in chronic pelvic pain due to endometriosis: a comparative study. Gynecol Obstet Invest.
2011;72(1):15-9. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21606636. Accessed April 12, 2012.
31. Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic
pain in men. J Urol. 2005;174(1):155-60. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15947608. Accessed January 4, 2012.