Telerehabilitation for persistent Pelvic Girdle Pain within a biopsychosocial framework - A case report.

BACKGROUND: Persistent pregnancy-related pelvic girdle pain (PGP) and the resulting consequences may considerably influence a woman's quality of life. The complexity of this condition requires a whole-person centered approach. In response to COVID-19 outbreak, telerehabilitation has emerged as a promising alternative to traditional in-person visits. PURPOSE: The aim of this report was to present the potential of telerehabilitation for persistent postpartum PGP within the biopsychosocial framework. CASE DESCRIPTION: A 26-year-old female presented with persistent pregnancy-related PGP of 8 months duration after her first vaginal delivery. The video-consults were performed using telerehabilitation platform. The patient received six telerehabilitation consults of 45 min duration over five weeks. Assessment of physical and psychosocial factors, cognitively focused strategies including pain neurophysiology education, sensory-motor remapping exercises, and graded increase of activity were administered. Rehabilitation was divided into the following phases: assessment, desensitization, graded exposure, and supported independence. OUTCOMES: The Pelvic Girdle Questionnaire (PGQ) score was significantly reduced from 72.2 during the assessment to 15.3 at discharge. This change was significantly more substantial than the minimal clinically important change estimated for the PGQ. CONCLUSION: Physiotherapists can utilize telerehabilitation to assist them with enacting appropriate care measures for persistent PGP within a biopsychosocial framework.

Pelvic floor muscle tenderness on digital palpation among women: convergent validity with central sensitization.

BACKGROUND: Tenderness on palpation of the pelvic floor muscles (PFMs) is a clinical assessment tool used alongside other tests to identify PFM involvement in pelvic complaints including pelvic pain. Although reliability of PFM tenderness has been determined, validity has yet to be established. OBJECTIVES: To assess convergent validity of PFM tenderness on digital palpation with the presence of central pain mechanism, as determined by a score of greater than 40 on the Central Sensitization Inventory (CSI). A secondary objective was to assess the agreement between PFM tenderness and self-reported symptoms of PFM sensitivity. METHODS: Participants completed a battery of self-report questions, the CSI, and various physical assessments (blinded assessors). Convergent validity was assessed between tenderness on palpation and the CSI. Kappa statistics were used to determine agreement between tenderness on palpation and self-reported perineal pain, urinary urgency, dyspareunia, and dysmenorrhea. RESULTS: Ninety-nine female participants with hip or back pain and at least one self-reported symptom of pelvic floor dysfunction were included in the study (mean age 40.56±12.72 years). Convergent validity was found between PFM tenderness on palpation and scores greater than 40 on the CSI (X12=4.2,p=0.04). There was poor agreement between tenderness on palpation with dyspareunia (agreement 62.83%, Kappa=0.27), dysmenorrhea (agreement 55.75%, Kappa=0.14), or perineal pain (agreement 53.04%, Kappa=0.10). CONCLUSIONS: PFM tenderness on digital palpation confirmed convergent validity with CSI scores, suggesting central pain mechanisms. Clinicians may need to consider the role of central pain mechanisms in their clinical decision making when treating PFM dysfunction.

"The Overactive Pelvic Floor (OPF) and Sexual Dysfunction" Part 1: Pathophysiology of OPF and Its Impact on the Sexual Response.

INTRODUCTION: Overactive pelvic floor (OPF) muscles are defined as muscles that do not relax, or may even contract, when relaxation is needed, for example, during micturition or defecation. Conditions associated with OPF are multifactorial and include multiple possible etiologies and symptom complexes. The complex interplay between biological and psychosocial elements can lead to the persistence of OPF symptoms along with psychological and emotional distress. OBJECTIVES: (1) To review and contextualize, from a pathophysiologic perspective, the evidence for OPF, (2) to provide an overview of common clinical presentations and comorbidities of OPF, and (3) to discuss the effect of OPF on sexual function in men and women. METHODS: Review of the updated literature on the pathophysiology of OPF was carried out. OPF-associated conditions were overviewed, with special emphasis on the impact on sexual function in men and women. RESULTS: Individuals with suspected OPF often present with a combination of gastrointestinal, gynecological, musculoskeletal, sexual, and urological comorbidities, mostly accompanied by psychoemotional distress. In both women and men, sexual function is significantly impaired by OPF and genitopelvic pain penetration disorders are often the primary manifestation of this condition. Women with OPF report less sexual desire, arousal, and satisfaction; more difficulty reaching orgasm; lower frequencies of intercourse; more negative attitudes toward sexuality; and more sexual distress than women without sexual pain. The most frequently reported sexual dysfunctions in men with OPF include erectile dysfunction, premature ejaculation, and ejaculatory pain. CONCLUSION: The complex pathophysiology of OPF involving multisystemic comorbidities and psychosocial factors emphasize the importance of a biopsychosocial assessment for guiding effective and personalized management. Padoa A, McLean L, Morin M, et al. "The Overactive Pelvic Floor (OPF) and Sexual Dysfunction" Part 1: Pathophysiology of OPF and Its Impact on the Sexual Response. Sex Med 2021;9:64-75.

The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients.

INTRODUCTION: The assessment of pelvic floor muscle (PFM) overactivity is part of a comprehensive evaluation including a detailed history (medical, gynecological history/antecedent), appraisal of the psychosocial contexts of the patient, as well as a musculoskeletal and a neurological examination. OBJECTIVES: The aims of this article are to review (i) the assessment modalities evaluating pelvic floor function in women and men with disorders associated with an overactive pelvic floor (OPF), and (ii) therapeutic approaches to address OPF, with particular emphases on sexual pain and function. METHODS: We outline assessment tools that evaluate psychological and cognitive states. We then review the assessment techniques to evaluate PFM involvement including digital palpation, electromyography, manometry, ultrasonography, and dynamometry, including an overview of the indications, efficacy, advantages, and limitations of each instrument. We consider each instrument's utility in research and in clinical settings. We next review the evidence for medical, physiotherapy, and psychological interventions for OPF-related conditions. RESULTS: Research using these assessment techniques consistently points to findings of high PFM tone among women and men reporting disorders associated with OPF. While higher levels of evidence are needed, options for medical treatment include diazepam suppositories, botulinum toxin A, and other muscle relaxants. Effective psychological therapies include cognitive behavioral therapy, couple therapy, mindfulness, and educational interventions. Effective physiotherapy approaches include PFM exercise with biofeedback, electrotherapy, manual therapy, and the use of dilators. Multimodal approaches have demonstrated efficacy in reducing pain, normalizing PFM tone, and improving sexual function. Multidisciplinary interventions and an integrative approach to the assessment and management of OPF using a biopsychosocial framework are discussed. CONCLUSION: Although the efficacy of various intervention approaches has been demonstrated, further studies are needed to personalize interventions according to a thorough assessment and determine the optimal combination of psychological, physical, and behavioral modalities. Padoa A, McLean, L, Morin M, et al. The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients. Sex Med 2021;9:76-92.

Predictors of Pelvic Floor Muscle Dysfunction Among Women With Lumbopelvic Pain.

BACKGROUND: There is evidence to suggest that a large proportion of individuals seeking care for lumbopelvic pain also have pelvic floor muscle dysfunction (PFMD). Because the majority of physical therapists do not have the requisite training to adequately assess pelvic floor musculature, determining predictors of PFMD could be clinically useful. OBJECTIVE: The objective was to establish a combination of factors (self-report and physical) predictive of PFMD in women with lumbopelvic pain. DESIGN: This was a cross-sectional study. METHODS: Participants completed a battery of self-report and physical assessments (masked assessors). Three clinical findings characterized PFMD: weakness of the pelvic floor, lack of coordination of the pelvic floor, and pelvic floor muscle tenderness on palpation (bilateral obturator internus). Univariate and multivariate logistic regression analyses were used to determine the extent to which different predictors were associated with PFMD. RESULTS: One hundred eight women with self-reported lumbopelvic pain (within the past week) were included in the study (mean age = 40.4 years; SD = 12.6 years). None of the examined factors predicted pelvic floor muscle weakness. Two factors independently predicted pelvic floor muscle tenderness on palpation: very strong and/or uncontrollable urinary urges (odds ratio [OR] = 2.93; 95% confidence interval [CI] = 1.13-7.59) and Central Sensitization Inventory scores of 40 or greater (OR = 3.13; 95% CI = 1.08-9.10). LIMITATIONS: The sample consisted of young women, some of whom were not actively seeking care. Additionally, the technique for assessing pelvic floor muscle tenderness on palpation requires further validation. CONCLUSIONS: Women who have lumbopelvic pain, uncontrollable urinary urgency, and central sensitization were, on average, 2 times more likely to test positive for pelvic floor muscle tenderness on palpation. Further studies are needed to validate and extend these findings.

Association between lumbopelvic pain and pelvic floor dysfunction in women: A cross sectional study.

BACKGROUND: The prevalence, cost and disability associated with lumbopelvic pain continues to rise despite the range of available therapeutic interventions, indicating a deficiency in current approaches. A literature base highlighting a correlation between lumbopelvic pain and pelvic floor function is developing; however, the features that characterize this correlation have yet to be fully established. PURPOSE: The purpose of this study was to determine the prevalence and characteristics of pelvic floor muscle function among women with lumbopelvic pain. METHODS: A cross-sectional study was conducted on non-pregnant women presenting with lumbopelvic pain to one of seven outpatient orthopaedic clinics in Canada. Potential participants underwent a screening process to assess for pelvic floor muscle dysfunction. RESULTS: A total of 182 women were recruited and 97 were excluded, leaving 85 participants (n = 85). Of these, 95.3% were determined to have some form of pelvic floor dysfunction. Specifically, 71% of the participants had pelvic floor muscle tenderness, 66% had pelvic floor weakness and 41% were found to have a pelvic organ prolapse. Participants with combined low back pain and pelvic girdle pain presented with higher levels of disability and increased characteristics of pelvic floor dysfunction. CONCLUSIONS: Our findings corroborate and extend recent research supporting the hypothesis that a high proportion of pelvic floor muscle dysfunction is present among women with lumbopelvic pain. Specifically, increased pelvic floor muscle pressure-pain sensitivity represented the most frequent characteristic, the clinical implications of which require further study.

Physical Therapy in the Treatment of Central Pain Mechanisms for Female Sexual Pain.

INTRODUCTION: The complexity of female sexual pain requires an interdisciplinary approach. Physical therapists trained in pelvic health conditions are well positioned to be active members of an interdisciplinary team addressing the assessment and treatment of female sexual pain. Changes within physical therapy practice in the last ten years have resulted in significant utilization of pelvic floor muscle relaxation and manual therapy techniques to address a variety of pelvic pain conditions, including female sexual pain. However, sexual pain is a complex issue giving credence to the necessity of addressing all of the drivers of the pain experience- biological, psychological and social. AIM: This review aims to reconcile current pain science with a plan for integrating a biopsychosocial approach into the evaluation and subsequent treatment for female sexual pain for physical therapists. METHODS: A literature review of the important components of skilled physical therapy interventions is presented including the physical examination, pain biology education, cognitive behavioral influences in treatment design, motivational interviewing as an adjunct to empathetic practice, and the integration of non-threatening movement and mindfulness into treatment. MAIN OUTCOME MEASURE: A single case study is used to demonstrate the biopsychosocial framework utilized in this approach. RESULTS: Appropriate measures for assessing psychosocial factors are readily available and inform a reasoned approach for physical therapy design that addresses both peripheral and central pain mechanisms. Decades of research support the integration of a biopsychosocial approach in the treatment of complex pain, including female sexual pain. CONCLUSION: It is reasonable for physical therapists to utilize evidence based strategies such as CBT, pain biology education, Mindfulness Based Stress Reduction (MBSR), yoga and imagery based exercises to address the biopsychosocial components of female sexual pain.