IUGA 2015 - Nice - France

PT PhD Maura Seleme

Workshop Session 1 – June 9, 2015 8:00 AM-12:00 PM

Management of Chronic Pelvic Pain: What is the Evidence?

Hands-On WorkshopChair: Sohier Elneil

Co-Chair: Vani DandoluFaculty: Vikram Khullar, Maura Seleme, Alex Digesu

Chronic pelvic pain

Chronic pelvic pain is a prevalent condition which can present a major challenge to health care providers

complex etiology and poor response to therapy.

multifactorial condition and quite often, poorly managed.

requires knowledge of all pelvic organ systems and their

association with other systems and conditions,includingmuscleskeletal, neurologic, urologic, gynaecological and

psychological aspects

requires multidisciplinary approach.

The European Association of Urology (EAU) Guidelines,2012

Management of neuropathic pain

A multidisciplinary team is necessary for pelvic neuropathic pain.

A key first step is a thorough clinical examination to map

the pain site physically and to identify potentially involved nerves.

Limited evidence exists about how best to manage

neuropathic pain

Frank F. 2011

PFM dysfunctions

underactive (hypotone)

pelvic floor

overactive (hypertone)

pelvic floor

disorder coordination

pelvic floor dysfunction, pelvic pain

urinary function: frequency,hesitancy, urgency, dysuria, bladder pain, urge incontinence

Stephanie S. Faubion,2011

Pain

deep into pain history:

– site of pain confirmed by pain diagram

– duration of pain

– nature of onset or precipitating event

– pain characteristics

– response of pain to activity and associated symptoms

Hopwood 2000

Inclusion criteria –pudendal nerves

Pain in the area innervated by the pudendal nerves that extends from

anus to clitoris

Pain more severe when sitting

Pain characteristics: burning, shooting, stabbing, numbing

Allodynia or hyperesthesia

Pain progressively worse

throughout the day

Pain predominantly unilateral

Pain triggered by defecation Tu, 2011

Visual analog scale

Em que número a paciente situa sua

Every session:

Session 1:

Session 2:

...........

Last session:

Before start the treatment… Following initial evaluation, all patients should be provided with

a detailed review of findings and explanation of the nature

and likely causes of their problem

if the initial findings do not preclude direct treatment for the

sexual problem, patients should be informed as to the

available treatment options and the likely benefits and

disadvantages or risks of each option

patients should always be encouraged to participate actively in

the decision-making process – motivation !

Information !

information anatomy & PFM

Talking about perineum !!!!!

https://www.youtube.com/watch?v=P3BBAMWm2Eo

Hot Bag

Aveiro at al 2009

Breathing exercises

Anterversion and retroversion

Find and Feel the perineum

Find and Feel the perineum

For increasing the perception Feel

Lying position on the side

Sitting position

Standing position

Always ask for a selectivecontraction ofthe pelvic floor muscles

Use evidence-based program!!!!!PFM training – SUI level 1, grade A ICI 2012

Program based on evidence Bø 1990,1999, DiNubile

1991, Mørkved 2002, 2003 , Bø 2004,Bø & Berghmans

2007

8-12 MAXIMAL contractions– inward & upward

6-8s contraction & relaxation

4 fast contractions– 8s of relaxation

3 sustained contractions 20s

contraction

relaxation

respiration

perceptionPFMT and female sexual functionPromising results of PFMT on sexual function

Duration of training: minimum 8 weeks Bo 2012

Trigger Points

Anderson et al 2009

Trigger points

savefrom.net

Trigger point assessment and treatment

for Pelvic Floor triggers M 3 Seminar

Selectivity PFM contraction

30% of women do not contract their PFM correctly at their first consultation, even after thorough individual instruction

Benvenuti et al 1987, Bump et al 1991,

Bø et al 1988

Physical examination shown by

movies produced by

abafi-HOLLAND

2014

Seleme, Berghmans, Uchoa 2014

Guidelines on Stress

Urinary Incontinence -

Royal Dutch Society for

Physiotherapy (KNGF)

– 2011

Guidelines on Stress

Urinary Incontinence -

Royal Dutch Society for

Physiotherapy (KNGF)

– 2011

Guidelines on Stress Urinary Incontinence -Royal Dutch Society for

Physical Therapy (KNGF) – 2011

Abdominal evaluation by film

Pelvis mobility by film

Hips movement shown by film

Coccix evaluation shown by film

Pirifomis muscle shown by film

Pubis evaluation shown by film

Volontary Contraction

No contraction pelvic floor,No relaxation pelvic floorNo contraction and also non relaxation pelvic floor

Messelink, Benson and BerghmansICS Standartisation

Pelvic floor dysfunction should be classified according to “ICS

Standartisation”By palpation of the pelvic floor muscles, the contraction and relaxation are qualified:

Voluntary contraction can be absent, weak, normal or

strong, and voluntary relaxation can be absent, partial or complete.

Involuntary contraction and relaxation is absent or

present.

Based on these signs, pelvic floor muscles can be classified as follows:

• non-contracting pelvic floor

• non-relaxing pelvic floor

• non-contracting, non-relaxing pelvic floor.

Messelink, Benson and Berghmans

ICS Standartisation

Anal Contraction by film

Inspection – movement duringcoughingpushing

Valsalva and perineum bulgingdown

Clitoris reflex

With swab is better !!!!!

Sensibility

Tonus of the center tendineum

Evaluation before invasivetechniques – finding

external pain

Finding Internal Pain

watch out: be aware of body work in relation to patient’s intimacy and reaction

Slow Contraction

10 s

Fast Contraction

Contraction and relaxation 15 seconds

Guidelines on Stress Urinary Incontinence -Royal Dutch Society for

Physical Therapy (KNGF) – 2011

Invasive Techniques

to show before the examination and first treatment an anatomical board with the muscles and intern organs localization

Talking about perineum !!!!!

Electrotherapy GOAL It can be used to reduce the pain:TENS !!!!!!

Conventional TENS– It will be responsible for the pain “gate closing”.

Frequency between 90 e 130 Hz

TENS Endorphin liberation–besides stimulating the liberation of β-endorphin, it also causes the muscle fiber relaxation, toxins removal and local

metabolism improvement. To do so, it is used frequency always lower than 10 Hz and impulse duration around 180 up to 250 μseg.

Fall & Madersbacher 1994AGNE, Jones Eduardo. Eu sei

eletroterapia. Santa Maria: Pallotti, 2009.

Chronic pain !!!!!

Acute pain !!!!!!!

Eletroterapy

Manual therapy and sexual dysfunction

Myofacial Training Effects:RelaxationEnhanced flexibilityIncrease of blood circulationPain reductionSensory perceptionScar tissue manipulationReduction of fibrotic adhensionsReduction of hypertonicity

GRIESE, Maurenne. Preparing for Birth: Perineal Massage. 2000

CASSAR, Mario-Paul. Manual de massagem terapêutica. São Paulo: Manole,

2001.

BECK-GALLAGHER, Krista. Episiotomy – Is It Necessary? 2000.

Myofascial Techniques

Musculoskeletal findings in cpps

patients presenting with urologic symptoms often active TrPs anteriorly and laterally within

levator musculature or in obturator internus Srinivasan 2007

Trigger Points

Anderson et al 2009

Trigger points in the levator ani

Butrick CW. Pathophysiology of pelvic floor hypertonic

disorders. Obstet Gynecol ClinNorth Am. 2009;36(3):699-705.

At a minimum, single-digit palpation

for chronic pelvic pain should include

the levator ani

Manual therapy and sexual dysfunction

Biofeedback through EMG Biofeedback through EMG –

nowadays it can be as stable as the pressure registration.

It allows the use of small probes, applying biofeedback and electrotherapy at the same time

It doesn´t allow variables of muscle stretching and can be modified according to hormonal impregnation and vaginal opening size.

Dabbadie e Seleme,2005

Receive the action Potential of the Motor Unit Muscle fiber depolarization -contraction -repolarization – rest

Binder,2002

Observation and analise the restingbase line tonus

Findings pain points

Pelvic floor hyperactivity

normal activity

hyperactivity

How to relax the pelvic floor withbiofeedback

MOVIE

Biofeedback

New technology in functional training

The Statics and Dynamics Abdomino-Pelvic

Good posture !!!!

N (%) with trigger point present in that muscle

Hip girdle musculature

Gluteus Medius/Minimus 31 (69%)

Adductor Muscles 33 (72%)

Obturator Externus 24 (52%)

Iliacus 26 (56%)

Psoas Major/Minor 31 (67%)

Abdominal wall musculature

Rectus abdominis 31 (67%)

Internal Obliques 16 (35%)

Transversus 16 (35%)

External Obliques 15 (33%)

Hip Girdle/Trunk

Gluteus Maximus 21 (46%)

Piriformis 27 (59%)

Quadratus lumborum 24 (52%)

Musculoskeletal disorders in cpps results

Tu et al 2008

Other painful regions ... Piriformis Muscles

Other painful regions ... Adductors Muscles

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