Chronic Pelvic Pain
What is Chronic Pelvic Pain?
Chronic pelvic pain can be defined as nonmenstrual pain of 3 or more month’s duration that localizes to the anatomic pelvis and is severe enough to cause functional disability and require medical or surgical treatment. Chronic dysmenorrhea or menstrual pain of 6 or more month’s duration that causes functional disability and requires medical or surgical treatment is also appropriately included in the definition.
Often in CPP, the initial physical problem has lessened or even disappeared, but the pain continues because of changes in the nervous system, muscles, or other tissues.
This teaches us an important distinction:
- In acute pain, the pain is often a symptom of underlying tissue damage.
- In chronic pain, the pain itself has become the disease! Chronic pelvic pain is itself the diagnosis.
Pelvic Floor Dysfunction (PFD)
The goal of Physical Therapy for patients who have chronic pelvic pain is to relax the pelvic floor muscles and avoid overly stressing them. Many people have problems with this group of muscles and develop a condition called Pelvic Floor Dysfunction (PFD).
Structure and Function of the Pelvic Floor
Structure and form in the pelvic floor arise from the interaction of muscles, nerves and ligaments acting on the pelvic organs. The vagina and ligaments must be stretched to their limit of extension to attain the strength required to carry loads. Unequal balance of the forces may stretch the system one way or the other, thereby contributing to many dysfunctional problems such as chronic pelvic pain and continence issues.
Suspension Bridge Analogy
The suspension bridge analogy illustrates how the pelvic structures are interdependent. In a suspension bridge strength is maintained through tensioning of suspensory steel wires (arrows). Weakening any one part of the structure may disturb the equilibrium, strength and function of the whole.
Myofacial Trigger Points (MTrP)
A Myofascial trigger point is an area of elevated neurological activity located in muscle/ fascia (connective tissue) that may refer pain in a localized or peripheral manner.
The trigger points feel like lumps in the muscle or connective tissue that are extremely sensitive to pressure. Trigger points often become self perpetuating once they have taken hold. Releasing trigger points typically requires active treatment.
Each specific trigger point on the body has a referred pain or other symptom pattern. Myofascial TrPs can entrap the nerves, blood, and lymph vessels, causing a variety of symptoms that confuse doctors and patients alike. Therapy includes direct manipulative techniques externally and internally that will improve abnormal musculoskeletal physiology.
Specific exercises to stretch or strengthen certain muscles or muscle groups may be advised and taught.
Possible Causes of Pelvic Pain and Pelvic Floor Dysfunction
If you have chronic pelvic pain, you may have a problem with something located in the pelvic area. However, your doctor will check for other possible sources for your pain. Pelvic pain during sexual intercourse, for example, may be a sign of a medical condition like endometriosis, irritable bowel syndrome or urethritis, or it may be related to past or present sexual abuse.
Many women do not realise that pelvic pain can actually be due to muscle problems in the abdominal wall or even back problems of the spinal discs or bones that are referred or perceived as being in the pelvic area. This type of pain is broadly categorized as myofascial pain.
Certain questions help to categorise the pain as more likely to be musculoskeletal in origin rather than urogenital organ in origin if:
- You have a history of musculoskeletal injury to the back, hips or knees.
- Your occupation is sedentary or labor intensive.
- You have repetitive musculoskeletal or postural stressors.
- Physical activity worsens or lessens the pain.
- Positional changes (lying to sitting, sitting to standing) worsen or relieve the pain.
- The pain changes with the time of day.
- There is noticeable muscle weakness or numbness or tingling.
- There is a history of inflammatory disease such as rheumatoid arthritis.
Treatment of Trigger Points
Treatment includes direct manipulative techniques externally and internally that will improve abnormal musculoskeletal physiology. Specific exercises to stretch or strengthen certain muscles or muscle groups may be advised and taught. These techniques will also be taught to your spouse/significant other so you can obtain the most benefit from your treatments.
Ancillary techniques may also be used, including TENS (Transcutaneous Electrical Nerve Stimulation), ultrasound, or various biofeedback methods. Relaxation and breathing exercises may also be taught.
During the course of evaluation and treatments, you must see your physical therapist at regular preset intervals rather than just when the pain gets worse. You may begin with weekly or monthly visits with increasing or decreasing frequency as determined by your progress.
Pelvic Stabilization and Therapeutic Exercise to Restore Dysfunction
Because the body's center of gravity is located at the pelvic level, it is very important that a person is able to hold proper pelvic position. If there is a pelvic rotation, it will cause unwanted postural changes and dysfunctional movement patterns that ultimately lead to pain. Trauma will also cause pelvic distortions and destabilize the center of gravity.
Physical Therapists are trained to recognise pelvic rotations and distortions and know how to restore balance to this area of the body. This will assist other areas of the body to heal.
Biofeedback
Biofeedback is a process for the re-education and training of patients control mechanisms based on visual and auditory muscle pressure sensor readings. Biofeedback is especially beneficial to individuals who have difficulty isolating their pelvic floor muscles during pelvic floor muscle retraining.
The Maher Sports and Wellness Centre utilizes Rehabilitative Ultrasound Imaging and EMG as a diagnostic and treatment modality.
What to expect on your first visit
A Physical Therapy evaluation can play an integral part in the recognition of many chronic pelvic pain conditions. Your musculoskeletal system will be evaluated by Dr. Ruth M. Maher, PT during a comprehensive examination.
Your posture, gait, abdomen, pelvis, and lower extremities will be checked. You will also have an "internal" exam. Information concerning abnormalities muscle strength, tenderness, length, and flexibility will be noted.
You will also be asked to complete a pain and quality of life questionnaire.