Joining Forces

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Chronic pelvic pain is a condition that, according to Mathias et al[i], affects approximately 15% of females between the ages of 18-50.  One type of pelvic pain, myofascial pelvic pain, is characterized by trigger points (taught muscle bands) within muscle fibers as well as pelvic pain. Typically, acetylcholine is a neurotransmitter released by motor neurons of the nervous system to activate muscles.  According to Borg-Stein et al[ii], chronic pelvic pain is associated with excessive acetylcholine release at the motor end plate nerve terminal.  This results in prolonged muscle contractions during times when the muscles are supposed to be at rest.  This results in pain and decreased tissue oxygenation.

Historically, treatment for myofascial pelvic pain includes manual physical therapy (such as myofascial release), trigger point injections to the local taught muscle “knots,” and medication (which is less popular due to often poor patient outcomes, undesired side effects, and/or poor compliance).  Researchers have recently explored a surprising alternative, namely onabotulinum toxin A, aka Botox.  While most people associate Botox with wrinkles or spasticity, the drug is now being used to treat the pelvic floor.  Botox works by preventing acetylcholine release at the motor end plate, thereby allowing the muscles that are chronically in an “on” state to be turned “off.”

A recent study by Halder et al[iii] explored the benefit of combined myofascial release along with Botox injections.  Women eligible to participate in the study included women who experienced chronic pelvic pain, demonstrated presence of pelvic floor muscle trigger points (indicated by pain during muscle contraction), and failure of previous intervention.  The experimental group treatment included Botox injections (under general anesthesia) followed by transvaginal soft tissue myofascial release for 10-30 minutes.  Participants were re-assessed between 2-8 weeks following the treatment.  At that time, only 44% of participants demonstrated trigger points upon digital palpation (vs. 100% pre-treatment) and 58% of participants reported decreased pelvic pain.

This study indicates that the future of overactive pelvic floor rehabilitation strongly suggests combining medical and manual physical therapy modalities. One of the things I love most about being a pelvic floor physical therapist is the holistic and collaborative nature of this specialty.  It is important to remember that chronic pelvic pain is often a complex puzzle with many pieces to address.  It often requires a team approach and multi-disciplinary attention.  Studies such as these prove that a combination of interventions is an approach that should be considered.  Medical care providers serve their patients best when they can distinguish what falls within versus beyond their scope of practice.  May we have the humility to recognize when to join forces appropriately with other medical care providers in order to best benefit our patients.

[i] Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol. 1996;87:321–327.

[ii] Borg-Stein J, Simons DG. Focused review: myofascial pain. Arch Phys Med Rehabil. 2002;83(3 Suppl 1):S40–S47. S48–S49.

[iii] Halder GE, Scott L, Wyman A, et al. Botox combined with myofascial release physical therapy as a treatment for myofascial pelvic pain. Investigative and Clinical Urology. 2017;58(2):134-139. doi:10.4111/icu.2017.58.2.134.

Lecture at Robert Wood Johnson University Hospital

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I recently had the opportunity to present a lecture on bowel dysfunction to the GI fellows at Robert Wood Johnson University Hospital.  This incredible opportunity afforded me the ability to educate budding new professionals at the beginning of their career on the benefits of pelvic floor physical therapy in relation to gastroenterology disorders.

The lecture focused on fecal incontinence and constipation as paradigms of underactive and overactive pelvic floor dysfunction, respectively.  It addressed the various components of a pelvic floor physical therapy initial evaluation, including food and fluid intake, toileting habits, and tests and measures.  It also explained the differences between treatment approaches for underactive versus overactive pelvic floor dysfunction.  The final section of the lecture focused on the benefits of biofeedback and how it can be utilized to educate patients on how to properly activate or release tension within the pelvic floor muscles, depending on the patient’s individual needs.

My personal favorite moment was at the end of the lecture, during the Q and A portion.  One of the fellows turned to me and remarked, “This information is so important!  Why don’t they teach us this in medical school?”  I responded, “I, know, RIGHT?!  But don’t worry.  If it makes you feel any better, they don’t teach this to us in physical therapy graduate school either.  My pelvic floor knowledge derives from continuing education courses and on-the-job training.”  And that is why I have made it my mission to share the wealth with as many physicians and laymen as possible.  The more informed we are in general about pelvic floor dysfunction, the more likely that those who need it will be properly diagnosed and referred for treatment in a timely manner.

For those of you who wish you could have been there to learn all about this fascinating topic, fear not and FOMO no more!  I have included the lecture in today’s blog post for your listening pleasure.  I hope you enjoy the lecture, and I encourage you to continue sharing the wealth with others.