Physical therapy for chronic pelvic pain in women

MOHAMED GAMALABOUELYAZEED
ASSISTANT LECTURER OF PHYSICAL
THERAPY FOR WOMEN’S HEALTH
SOUTH VALLEYUNIVERSITY

Physical Therapy
for
Chronic Pelvic Pain
in Women

*Chronic Pelvic Pain is defined as intermittent or
constant pain in the lower abdomen or pelvis of at least six months
duration, that does not occur exclusively with menstruation or
intercourse (Royal College of Obstetricians and Gynecologists,
2012).
*Its etiology has not been fully understood yet, and
it has a complex, multifactorial natural history and is
resistant to treatment It may be caused by one or
more different conditions (Ahangri, 2014) and
seriously affects the individual's work, family, and social life (Bishop,
2017) & ( Juhan, 2015) .
*While chronic pelvic pain is a
symptom caused by one or more different
causes. Chronic pelvic pain is a common
problem. prevalence in general ranged
Between 5.7% and 26.6% (Ahangari, 2014).

*CPP is a complex and multifactorial disorder withthe
involvement of many organs including the urological, gynecological,
musculoskeletal, and gastrointestinal systems.
*CPP is thought to have gynecologiccauses
(originating in the female reproductive tract) in
approximately 20% of women (Frank and Sawsan, 2019).
*In addition, the treatment requires an integrated approach in which
simultaneous consideration is paid to somatic, psychological, and
social aspects. Conservative management gives satisfactory results
in a high proportion of patients with CPP (Meltem, 2018).

*Some of the gynecologic causes of chronic pelvic pain:
 Endometriosis.
 Uterine Fibroids.
 Ovarian cysts.
 Pelvic adhesions.
 Adenomyosis.
 Pelvic inflammatory disease.
 Pelvic congestion syndrome.

*Some of neuromusculoskeletal causes of CPP:
Sacroiliac joint dysfunctions.
Symphysis pubis dysfunctions.
Pudendal neuralgia.
Pelvic floor Trigger points.
Abdominal muscles trigger points.
*Other causes of chronic pelvic pain include:
Irritable bowel syndrome.
Chronic constipation
Interstitial cystitis.
Major depression.
Fibromyalgia.

*A careful and detailed history is extremely important for CPP:
-The history of the patient with CPPshould
include urinary, gastrointestinal, gynecological,
musculoskeletal, sexual, and psychosocial symptoms (Bradley et al.,
2017).
*The treatment and rehabilitation program of CPP can
be planned to address specific causes and/or general pain
management. Treatment should include a trial of conservative
therapies (e.g. patient education, physical therapy, pharmacotherapy
and psychotherapy) that can often provide significant symptom relief
and improved quality of life (Gritsenko and Cohen, 2017).

1- ENDOMETRIOSIS
*Endometriosis is a common and chronic disease in women of
reproductive age that is characterized by the presence of endometrial
glands and stroma outside the uterus.
*It is estimated to be present in almost 10%
of women in their reproductive age, in around
20% of women with chronic pelvic pain and
in almost 30-50% of women with infertility.
*Like the true endometrium, it responds to cyclic hormonal changes
and bleeds at menstruation producing pelvic pain and adhesions with a
progressive course in 30-60% of cases.
*Laparoscopy is the gold standard for diagnosis& the only for staging.
TVS & MRI may be used initially as in ovarian chocolate cysts.

Risk factors:
-Women with high socioeconomic standard and early menarche.
-Women in the mid reproductive age 25-35 years
-Women with infertility, nulliparity and low parity
-Women with familial history of endometriosis
Sites of endometriosis:
(A)Pelvic (common) sites→
Fallopian tubes, Ovaries, Pelvic
peritoneum, Uterosacral ligament
, Sciatic nerve, Obturator nerve
and Pelvic floor muscles.
(B) Extra pelvic (uncommon)
sites→ Lungs, Umbilicus, Kidney
, Abdominal wall, C-section scar,
Diaphragm and Brain.

The etiology of endometriosis is not yet fully understood.
1)Sampson theory (retrograde menstruation): it suggest that viable
endometrial tissue is transported through fallopian tubes during
menstruation and it explains pelvic endometriosis only.
2)Lymphatic spread theory: it suggests
that endometrial tissue is transported via
lymphatic system to various distant extra
pelvic sites such as lungs and brain
3)Coelomic metaplasia theory: proposes
that multipotential cells in the peritoneal
tissue undergo metaplasia transformation
into functional endometrial tissue.
4)Altered immune response theory:
women with endometriosis may have an
altered immune response that makes them
less likely to recognize the extra uterine
endometrial tissue to clear implants.

*Clinical Features of Endometriosis:
-Many cases may remain asymptomatic for long times until accidentally
discovered during laparoscopy or laparotomy.
-Signs: Tender&painful nodules may be palpated during PV examination
-Symptoms :
*May be only suggestive as they are not specific
to endometriosis.
*Symptoms do not necessary correlate with
severity or extent of the disease as: Marked
pelvic disease may be absent and Small
endometriotic pelvic implants may produce significant symptoms.
*The 2 major clinical presentations of endometriosis are Pelvic pain
and/or Infertility.
(A) Pelvic pain:
*Dysmenorrhea → secondary dysmenorrhea is one of the commonest
clinical presentation.

*Onset of pain usually precedes flow by a few days and begins to
resolve 1-2 days into the menses and
prolonged heavy flow of 8 or more days.
*Symptoms also usually improve during
pregnancy and after menopause.
*Pain may be due to endometrial implants that distend and bleed in
response to cyclic hormonal changes during menstrual cycle without
having an exit. also, chemical irritation to nociceptors.
*pain may be reduced gradually toward the end of menstruation
due to absorption of blood within the endometriotic implants.
*Chronic pelvic pain → diffuse or localized chronic pelvic pain that
lasts at least for 6 months is strongly suggestive of endometriosis.
*Dyspareunia → up to 50% of women complain of endometriosis
may suffer from dyspareunia. It maybe due to endometrial implants on
the ovaries, pouch of Douglas, uterosacral ligament or RVF uterus.

(B) Infertility:
*Moderate to sever endometriosis → may compromise fertility through
creating pelvic adhesions, which may be peritubal (Prevent fertilization
or implantation) or periovarian (prevent ovulation or ovum pick up).
*Mild endometriosis → may compromise fertility by increased tubal
phagocytic macrophage
activity on the sperms.
(C) Other symptoms:
*GIT symptoms→
Intestinal cramps,
Pain during defecation and rarely cyclic rectal bleeding
*Urinary symptoms → dysuria and rarely cyclic hematuria.
*Distant metastasis → symptoms according to the involved organ
(Brain and Lungs).

Treatment of endometriosis:
Conservative →
-Mild to moderate pain without complications
*NSAIDs and continuous hormonal contraceptives
*NSAIDs alone if pregnancy is desired
-Severe symptoms
*GnRH agonists for 6-9 months induce
pseudo menopause state but they are
expensive and have a serious side effects.
Surgical therapy →
-First-line: laparoscopic excision and
ablation of endometrial implants and adhesiolysis
-Second-line: open surgery with hysterectomy with or without
bilateral salpingo-oophorectomy.

Physical Therapy for Endometriosis
*Relaxation training and reassurance
* Pain relief electrical stimulation (TENS) and Heat
*Ultrasound therapy
*Manual visceral manipulative techniques
*Therapeutic exercises especially Pelvic floor exercises
1-Relaxation training:
Progressive muscular relaxation (PMR) training is effective in
improving anxiety, depression and Quality of life( QOL ) of
endometriosis patients under GnRH agonist therapy. This is the first
study to explore the effects of psychosomatic therapy on emotional
status and QOL of endometriosis patients, and may serve as an
important reference for future psychosomatic interventions on
endometriosis ( Zhao and Chen 2012).

2-TENS:
Frequency: (Low frequency TENS 2-10 HZ)
Pulse width: 250 microseconds
Intensity: according to patient’s tolerance with
strong but comfortable muscle contraction
Duration: 15–30 min.
Mechanism: Endogenous (descending pain) theory
*(acupuncture-like TENS) demonstrated effectiveness as a
complementary treatment of pelvic pain and deep dyspareunia,
improving quality of life in women with deep endometriosis (Ticiana
et al.,2015).

3-Ultrasonic Therapy:
Frequency: 1MHZ
Mode: Continuous (100% duty cycle)
Intensity: 1.5 W/cm2
Duration: 15min. on each endometrial implant site
Mechanism: Therapeutic ultrasound has been
shown to increase the extensibility of collagen
bands on the surface of the adhesions and facilitate
the stretching of adhesions by heating
(↑collagenase activity) and micro massaging
effects . Also, it aids resorption of adhesions by
depolymerisation of mucoproteins and
glycoproteins.

*This study concluded that ultrasound therapy
had an excellent effect in the management of
chronic pain as a result of endometriosis as well
as reducing adhesions and can be considered
as an alternative method for treating such cases
without any side effects or complications to the patient there was a
highly significant decrease in the severity of pain between before and
after the end of 12 as well as 24 sessions of ultrasonic treatment and
there was a highly significant decrease in the degree of endometriosis
diagnosed by laparoscopy between before and after the end of 24
sessions of ultrasonic treatment. (Mansour et al., 2009).

4-Manual visceral manipulation:
*The manual physical therapy represented an effective, conservative
treatment for women diagnosed as infertile due to mechanical causes,
independent of the specific etiology (Rice et al., 2015).
*Female infertility is a complex issue encompassing a wide variety of
diagnoses, many of which are caused or affected by adhesions.
*The Efficacy of a Manual Physical Therapy to Treat Female
Infertility:
-The research team designed a retrospective chart review.
-The study took place in a private physical therapy clinic.

-Participants were 1392 female patients who were treated at the clinic
between the years of 2002 and 2011. They had varying diagnoses of
infertility, including occluded fallopian tubes, hormonal dysfunction,
and endometriosis, and some women were undergoing in vitro
fertilization (IVF).
-Patients were treated using an individualized physical therapy treatment
plan that was named the CPA(Clear Passage Approach) protocol which
focused on restoring mobility and motility to structures affecting
reproductive function by minimizing adhesions and decreasing
mechanical blockages in order to improve mobility of soft tissue
structures. Visceral manipulation was also used to help restore normal
physiologic motion of organs with decreased motility.

- Improvements demonstrated in the condition(s) causing infertility
were measured by improvements in tubal patency and/or improved
hormone levels or by pregnancy .
The results included a 60.85% rate of clearing occluded fallopian
tubes, with a 56.64% rate of pregnancy
in those patients. Patients with endometriosis
experienced a 42.81% pregnancy rate.
The reported pregnancy rate for patients who
underwent IVF after the therapy was 56.16%.

-All visceral manipulative techniques were preceded by muscular
decongestion technique to decrease pelvic congestion and improve
the circulation, allowing for more relaxation of the organs and tissues
being treated (Yousri et al., 2016) .
-The muscular decongestion technique
was done from crock lying position.
*The patient took deep diaphragmatic inspiration associated with
holding bridge position (elevated pelvis)
*With expiration the patient still in bridge while performing hip
abduction against therapist’s hand resistance
*During the next inspiration the patient performed hip abduction
against therapist’s hand resistance and during expiration she lowered
the pelvis to the plinth.
*Repeat the technique 5 times before applying visceral manipulation.

5-Therapeutic exercises:
*Pelvic pain have been associated with an alteration in the strategy for
lumbopelvic stabilization with insufficient as well as excessive motor
activation of the lumbopelvic and surrounding musculature (O'Sullivan
and Beales, 2007).
*Endometriosis is estrogen dependent disease and regular exercises for
3 months result in an overall decrease of free and total estradiol
concentrations according to 25 randomized controlled trials in this
systematic review and this may explain why exercises are helpful in
endometriosis (Ennour-Idrissi et al., 2015).
*Ultimately it was proven that 8 weeks of an exercise program of
posture correction exercises, relaxation with breathing and pelvic floor
stretching (3sessions /week and 30-60 min./session) is very effective in
decreasing pain and postural abnormalities such as kyphosis
associated with endometriosis (Awad et al., 2017) .

2-Uterine Fibroids
*Uterine leiomyomas (fibroids) are benign, hormone-
sensitive uterine smooth muscles neoplasms and fibroids are the
commonest tumor of the female genital organs and they rise from a
single myometrial cell (monoclonal growth).
*Prevalence: fibroids affecting as many as
25% of women in the reproductive age.
* Pathophysiology:
-Upregulation of hormone receptors, particularly estrogen and
progesterone
-Excessive production of extracellular matrix (hence "fibroids")
results in an overgrowth of smooth muscle cells and connective tissue
-The myometrium also develops vascular changes (e.g., increased
arterioles and venules, dilated veins).

*Predisposing factors:
-Nulliparity
-Early menarche (< 10 years old)
-Age: 25–45 years•
Fibroids are largely found in women of reproductive age
influenced by hormones (i.e., estrogen, growth hormone,
and progesterone)
-During menopause, hormone levels begin to decrease and
leiomyomas begin to shrink
-Increase incidence in African Americans
-Obesity
-Hypertension
-Family history

*Sites of uterine fibroids:
1) Corporeal leiomyomas:
*up to 95% of leiomyomas develop within
the uterine body and they are usually
multiple and of variable sizes.
*According to their relation to endometrium:
-Interstitial Myomas (ISM) → within the center of myometrium
-Subserosal Myomas (SSM) → raising the peritoneal covering of
uterus (serosa) externally and may acquire pedicle forming a
pedunculated SSM.
-Submucosal Myomas (SMM) → indenting the endometrial lining
and may protrude in the endometrial cavity and may acquire pedicle
forming a SMM polyp.

2) Cervical leiomyomas:
*4% of leiomyomas and usually are solitary.
-Portio-Vaginalis → growing downward to project in vagina and may
reach the introitus to be outside the vulva.
- Supravaginal cervix → growing upward in the true pelvis in relation
to the ureters, bladder, rectum and broad ligament.
3) Broad ligament leiomyomas:
*1% of leiomyomas and rare.
-Primary BLM → arising from the muscle
fibers of broad ligament (True BLM) and not connected to the uterus.
-Secondary BLM → SSM grows externally from the side of the uterus
and burrow within the leaves of broad ligament.

Clinical features of fibroids:
-Most women have small, asymptomatic fibroids.
-Symptoms depend on the number, size, and location of leiomyomas.
- TVS is the gold standard for diagnosis.
1)Abnormal menstruation:
-Polymenorrhea, menorrhagia & metrorrhagia
-Secondary dysmenorrhea
2 Features of mass effect:
-Enlarged , firm and irregular uterus in bimanual examination
-Back or pelvic pain/discomfort
-Urinary tract or bowel symptoms (e.g., urinary
frequency, constipation and hydronephrosis)
3 Reproductive abnormalities:
-Infertility
-Dyspareunia

Treatment of uterine fibroids:
*Treatment should only be considered in symptomatic patients
because of the side effects of medical therapy and surgery.
*The goal is to relieve symptoms.
*Asymptomatic fibroids:
-Do not require treatment
-Frequent follow-ups (every 6–12 months) are necessary to monitor any
potential growth.
*Symptomatic fibroids:
-NSAIDs → to reduce pain
-GnRH agonists → to induce pseudo menopause state
-Progestins → to decrease bleeding and related dysmenorrhea
-Uterine artery embolization → to reduce blood supply to fibroids
-HIFU guided by MRI → to destroy uterine fibroids
-Myomectomy or Hysterectomy → the only definitive treatments.

Ultrasonic therapy is effective in shrinking of the size of uterine
fibroids and improving of its related symptoms when US treatment
session was daily of total 6 sessions, using continuous US mode,
frequency (1MHz), intensity up to (2 w/cm2 ) and total time of each
session was 60 minute with 5 min interval for each 30 minute
(Mohamed et al.,2015).
*Chronic pelvic pain in women may have multifactorial etiology,
but 22% have pain associated with musculoskeletal causes.
Unfortunately, pelvic musculoskeletal dysfunction is not routinely
evaluated as a cause of pelvic pain by gynecologists (Gyang et al.,
2013).

 Performing a simple musculoskeletal screen along with a pelvic
muscle exam takes just a few minutes and adds valuable
information to the medical assessment. If MFPP is suspected or if the
musculoskeletal screening and pelvic floor muscle assessment
reproduces familiar symptoms or pain, then referral to a physical
therapist (PT) trained in this specialty is indicated (Schleip, 2003).
 Interventions such as use of modalities, pelvic-floor strengthening,
internal and external trigger point management, myofascial manual
therapy, stretching and flexibility exercises, spinal mobilizations,
nerve glides, and relaxation exercises all have been recommended as
effective physical therapist management of pelvic pain (Prendergast
and Weiss, 2003).

The Carnett test for patients with pelvic pain. The patient raises both
legs off the table while supine. Raising only the head while in the
supine position can serve the same purpose. The examiner places a
finger on the painful abdominal site to determine whether the pain
increases during the maneuver when the rectus abdominis muscles are
contracted. The assumption is that it potentially increases myofascial
pain such as trigger points, entrapped nerve, hernia, or myositis,
whereas true visceral sources of pain may be less tender when
abdominal muscles are tensed (Ortiz, 2008).

1)Sacroiliac dysfunctions
*In pregnant patients with hypermobility and laxity
of the SIJ, excessive stretching and mobilization may
aggravate SIJ pain. Therefore, clinicians should be extremely
cautious with therapy or any exercise prescriptions for pregnant
patients (Prather and Hunt, 2004) & (Damen et al., 2002).
*Physical Therapy for Sacroiliac dysfunctions:
*Therapeutic Exercises
*Manual therapy (Manipulation / Mobilization)
*Low Level Laser Therapy (LLLT)
*Ultrasound therapy
*Lumbopelvic Belts

The SIJ has a high level of stability from the self-locking
mechanisms of the pelvis, which comes from the anatomy and shape of
the bones in the SIJ (Form Closure) and also the muscles supporting
the pelvis (Force Closure).
Training should be performed at a frequency of 1 to 2 times a week
and focus on improving balance; active stability; strength of the
muscles of the lower back, pelvis, and pelvic floor; and co
contraction of the transverse abdominal and pelvic floor muscles
with other muscle groups (Martins and Silva, 2014).
1)Therapeutic exercises especially core stability:

 Core training exercises focus on restoring the timing and
sequencing of deep muscles. For the lumbopelvic region these
include transversus abdominis, multifidus, the pelvic floor and
breathing diaphragm.
MET directed at pelvic and sacral positional
faults and therapeutic exercise consisting of
transverse abdominis and multifidus
neuromuscular re-education, isometric hip
abduction and external rotation and
a force closure sacroiliac stabilization program directed at
neuromuscular re-education of the anterior and posterior oblique sling
systems is effective interventions for women complaining of posterior
pelvic pain (Hall et al., 2005).

2)Manual therapy (Mobilization & Manipulation):
*There is evidence for both SIJ manipulation and lumbar
manipulation. Following the performance of each of these
manual therapy techniques pain and functional disability are
significantly improved in patients diagnosed with SIJ syndrome.
Manual spinal thrust manipulation may be considered as a component of
effective treatment for patients with SIJ syndrome (Kamali et al., 2013).
*This study proved that a combination of mobilization with movement
and functional training was effective in reducing pelvis malposition and
pain, and improving static stability control (Son et al., 2014).

Low Level Laser Therapy was effective for sacroiliac pain, and this
may be due to improvement of the blood circulation of the strong
ligaments which support the sacroiliac joint, activation of the descending
inhibitory pathway, and the additional removal of irregularities of the
sacroiliac joint articular surfaces (Ohkuin et al., 2011).
 This study attempted to evaluate the effectiveness of ultrasound in
patients with sacroiliac joint dysfunction, ultrasound parameters
(1 MHz, 1 W/cm2, 5 min). The study demonstrated that therapeutic
ultrasound was beneficial in decreasing pain, improving unilateral
lower limb stance time (Chadichal, 2006).
3)Electrotherapy (LLLT & Ultrasonic therapy):

Pelvic belts improve health-related quality of
Life and are potentially attributed to decreased
SIJ-related pain. Belt effects include decreased
rectus femoris activity in patients and improved postural steadiness
during locomotion and The location of the sacroiliac belt should be
at the superior aspect of the PSIS to assist in stabilizing and
supporting the pelvis. Pelvic belts may therefore be considered as a
cost-effective and low-risk treatment of SIJ pain (Hammer et al.,
2015).
4)Lumbopelvic supportive belts:

*The incidence of pelvic girdle pain (symphysis
pubis dysfunctions) has been found to be higher
in late pregnancy and among women with a
higher BMI (Kovacs et al 2012).
*Physical Therapy for Symphysis Pubis dysfunctions:
*Core stability training
*Pelvic floor exercises
*Muscle energy techniques (Shotgun technique)
*Joint Mobilization
*Pelvic belts
*ElectrophysicalAgents
2)Symphysis Pubis dysfunctions

*Steps For a Shotgun Technique:
1.Therapist places hands outside of knees to give resistance and ask
patient to do isometric contractions toward abduction.
2.Hold x 10 seconds. Repeat 3 times
3.Then therapist places hands between patient knees and
ask patient to do isometric contractions toward adduction.
4.Hold x 10 seconds. Repeat 3 times
*Patient may feel or actually hear a slight “Click” as patient performs
this technique. it may means the symphysis pubis is adjusted.
*Advice to symphysis pubis dysfunctions patients:
-Keeping active but also getting plenty of rest.
-Keep legs together when getting in and out car & turning over in bed.
-Using a pillow between legs for extra support in bed.
-Lying on the less painful side while sleeping.
-Avoid standing on one leg or crossing legs.
-Avoid going up and down stairs too often.

3)Abdominal and Pelvic Floor Muscles
Trigger Points
*Trigger points form only in muscles. They form as a
local contraction in a small number of muscle fibers in muscle bundle.
*These trigger points are due to excessive release of acetylcholine
which produces sustained depolarization of muscle fibers, these
sustained contractions of muscle sarcomeres compresses local blood
supply restricting the energy needs of the local region. This crisis of
energy produces sensitizing substances that interact with some
nociceptive (pain) nerves traversing in the local region which can
produce localized pain within the muscle at the neuromuscular junction.

*Physical Therapy for Triggerpoints:
1*Ischemic compression technique
2*Myofascial release technique
3*Strain counterstain technique
4*Spray stretch technique
5*Dry needling
6*Ultrasonic Therapy
7*Moist heat application
 Manual therapy including ischemic compression technique,
myofascial release and stretching was effective in decrease
sensitivity of external pelvic trigger points in women who suffer
from chronic pelvic pain (Hanafy et al., 2016).
 Trigger points can be located in the pelvic floor muscles or the
abdominal wall musculature can be managed by trigger point
manual release, acupressure, muscle energy, and strain-counter
strain technique can be used for myofascial trigger points (Hwang,
2017).

 Effective treatment modalities for trigger pints are local heat and
cold, stretching exercises, spray-and-stretch, needling, local
injection, and high-power pain threshold ultrasound (Majlesi and
Unalan, 2010).
 Myofascial pelvic pain can be effectively treated with a variety of
physical therapy techniques, including manual therapy,
biofeedback, relaxation training, electrical stimulation, and self-care
modalities (Pastore and Katzman,2012).
 Systematic review for 11 studies in 2015 concluded that LLLT seems
to be effective for reducing MTrPpain. However its effect is
minimal when used as unique treatment (Corbetta et al., 2015).
 conventional US therapy is effective in the treatment of myofascial
pain syndrome (Yildrim et al., 2018).

4)Pudendal Neuralgia
*Pudendal neuralgia is long-term
pelvic pain that originates from
damage or irritation of the pudendal
nerve – a main nerve in the pelvis.
Causes:
-Damage to pudendal nerve during
childbirth is very common cause.
-Entrapment of the pudendal nerve by
nearby muscles or tissue Alcock canal
syndrome.
-Prolonged sitting, bicycling, horse riding or chronic constipation can
cause repeated minor damage to the pelvic area.
-Pelvic surgeries as some prolapse surgeries or pelvic bones fractures.
-Pelvic floor muscles spasm.

*The pudendal nerve is frequently compromised during child birth,
with incidence of 32% of all vaginal deliveries being reported.

*Physical Therapy for Pudendal Neuralgia:
-Core stability exercises
-Pelvic floor stretching and strength
-Biofeedback
-Heat application and TENS
-Low Level Laser Therapy
-Trigger point release
-Sacroiliac mobilization
-Hip rotators and abductors exercises
*The results of this study objectively demonstrates that proctalgia could
be manifestation of pudendal nerve compression and usage of low level
laser therapy (GaAlAs) with a wave length of 904nm, frequency of
5000Hz, power peak of 25 Watt, pulse duration of 200 nanosecond and
90 sec. for each point is an excellent, safe, very effective, non
pharmacological new method of alleviating proctalgia pain secondary to
pudendal nerve entrapment in comparison to traditional pain relief
modalities (Sabbour and Shafik, 2005).

*TENS of 80 Hz and 150 μs at the sensory threshold level was used for
30 min, twice a day was successful after a 12‐week treatment, the
positive effect was sustained in >70% during a mean follow‐up of 44
months. Importantly, no adverse events related to TENS occurred during
the study period. Thus, TENS may be an effective and safe treatment for
refractory chronic pelvic pain syndrome (Schneider et al., 2013).
*Various musculoskeletal impairments have been associated with
pudendal neuralgia, such as pelvic floor dysfunction, connective tissue
restrictions, myofascial trigger points, muscle hypertonicity, altered
neurodynamics, and structural and biomechanical abnormalities, such as
lumbopelvic dysfunctions (Prendergast and Rummer, 2006).
*This cohort study provides Level 2b evidence that a musculoskeletal
physical therapy approach including heat therapy, core stability
exercises and sacroiliac mobilization techniques has a positive
influence on pain and sexual dysfunction in a specific subgroup of
patients presenting with pudendal neuralgia (Dornan, 2012).

Physical therapy for chronic pelvic pain in women

Physical therapy for chronic pelvic pain in women

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Physical therapy for chronic pelvic pain in women

Similar to Physical therapy for chronic pelvic pain in women (20)

More from South Valley University, Egypt and Queen's University, Ontario

More from South Valley University, Egypt and Queen's University, Ontario (12)

Recently uploaded

Recently uploaded (20)

Physical therapy for chronic pelvic pain in women