Pelvic Pain Archives - Page 10 of 17 - Revitalize Physical Therapy

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.

Disney knew what they were doing when they made Scar the dangerous villain in the movie, The Lion King. That is because as a pelvic floor physical therapist, I can attest to the fact that scars are the enemy which can contribute to pelvic floor dysfunction and pain.

In general, scars are one of the most overlooked clinical findings that I encounter during treatment. Time after time, I will notice a post-surgical scar in an area seemingly unrelated to the pelvic floor (ex. mastectomy, hip replacement, hysterectomy) and inquire regarding what suggestions were made to the individual about proper scar care. An overwhelming majority of women inform me that they have not been educated at all on scar care or mobilization. In fact, some are even afraid to touch the scar “lest it open.” Scars may take the form of episiotomies, healed perineal tears (for vaginal deliveries), and C-section scars. All three of these scars may contribute to pain during intercourse, and a C-section scar can interfere with lumbar mobility, especially trunk extension.

In our bodies, movement equals health. Every muscle, joint, tendon, ligament, nerve, and connective tissue structure, including fascia, has some degree of mobility and movement. Scars are the enemy when it comes to mobility. Almost every wound or injury (including surgery) results in some amount of scarring. Scars are composed of a protein called collagen, and this is the same protein in healthy skin. However, the protein fiber composition in scars is different and less functional than the collagen that exists in normal tissue. In other words, the body may do “too good” of a job healing itself; stiff and excessive bundles of collagen growth accumulate near the scar. This interferes with the mobility of the local structures. So while scar formation is a necessary and a natural part of the healing process, the accompanying issue of decreased structural mobility must be addressed.

This is best accomplished by performing scar massage, a technique that can be performed by a physical therapist or on one’s own body. The general goal is to mobilize the tight tissue and release myofascial adhesions or restrictions caused by the scar. Many women find the following direct mobilization techniques helpful for abdominal C-section scars:

Using two to three fingers, apply force in a horizontal direction along the entire length of the scar (side to side, or right to left)
Using two to three fingers, apply force in a vertical direction along the entire length of the scar (up and down, or above to below)
Using two to three fingers, apply force in a circular or rotational direction along the entire length of the scar. Create circles in both a clockwise and a counterclockwise direction
Pinch, twist, and roll the skin along the entire length of the scar
Lift the overlying skin along the entire length of the scar.

These techniques help break adhesions and free up the underlying tissue in all directions. The amount of suggested force for all of these techniques is until the point prior to pain. Meaning, it should not hurt! If it does, try applying slightly less force. Furthermore, scar massage should not be performed until the skin has healed, which generally takes six weeks to occur. Please consult with your pelvic floor physical therapist or physician prior to initiating any scar mobilization program.

Category: Pelvic Pain

Joining Forces

Scary Scars