Pelvic Dysfunction: The Missing Link. Raza Awan, MD

Transcription

1 Pelvic Dysfunction: The Missing Link Raza Awan, MD

2 Disclosures None Housekeeping Thank You

3 Objectives By the end of this session participants will be able to: Identify the link between non-resolving low back pain and underlying pelvic muscle dysfunction Summarize the risk factors for pelvic muscle dysfunction Assess when it is appropriate to refer a patient to pelvic physiotherapy

4 But you re a sports doctor, right?

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6 2012 Chart Review

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11 Chronic Pelvic Pain CPP is difficult to diagnose and treat because pain symptoms may be the result of complex interactions between multiple body systems including urological, gynecological, neurological, gastroenterological, musculoskeletal, sexual, and psychological

12 Case 1

13 Case 1

14 Case 1

15 Case 1 A) Facet mediated pain Diagnosis? B) Disc mediated pain with L5 radicular symptoms C) SI joint pain D) Pyriformis dysfunction

16 Case 1 Diagnosis? Lumbar disc mediated pain with mild L5 radicular symptoms MRI mild disc protrusions L4/5 & L5/S1 Further treatment? Rehab Pilates? Osteopathy? Different physiotherapist? Meds? Injections? Pain management

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19 Do you have any trouble with your bladder or bowel function???

20 Sex?

21 Patients referred from sports doctors to pelvic physiotherapy N= 59; 51 women, 8 men Avg age = 42 Synergy Chart Review Women 86% Gender 2017 Men 14% Avg Symptom duration = 32 months Avg No of rehab providers seen = 2.6

22 Urogastrogenital Symptoms MD PT Bowel Bladder Sexual 0

23 Combined Symptoms Urine/Bowel/Sexual Urine/Bowel/Sexual MD PT

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25 Are you kidding me???

26 Potential Responses Mixed Many are shocked; skeptical; hadn t heard of it; seems like a bit of a stretch; not into it Some women have negative experiences with gyne exams or transvaginal US Uncomfortable, quick, tense Often ask if anything else can be done

27 Patient Education

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29 Case 1

30 Case 1 Treatment 6 Weeks 4 Sessions pelvic PT & home self release w/ wand Much improved 8 Weeks R side tone near normal; left mildly hypertonic Pain 90% better Back to spinning, walking long distances Started rehabilitation Pilates

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33 Pelvic Floor Dysfunction

34 Pelvic Floor Dysfunction Can occur as functional adaptation to other disorders within pelvis, hip or spine complex or from inherent cause in pelvic floor To resolve the issue though requires addressing the pelvic muscle function In many cases, low back or hip is now the victim; pelvic floor is the culprit

35 LBP and the Pelvic Floor With respect to LBP specifically, the pelvic floor is thought to contribute to the management of intra-abdominal pressure to support the transfer of loads during functional movement

36 Causes Direct injury Childbirth (can be from lower abdominal/pelvic scar from C-section also) Trauma/pelvic fx Surgery (pelvic/lower abdominal) Dyssynergia When try to relax, actually contract Neuropathy (ie. pudendal, IHG, IIN GFN) Gynecological Endometriosis, vulvodynia Urological Coccydynia Trigger points Unknown

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38 Historical Clues Pelvic pain Sx started peripartum H/o pelvic/lower abdominal surgery Urogastrogenital symptoms H/o sexual/physical abuse Gynecological problems H/o Coccyx trauma Can t get core or hip exercises or exercises painful Non resolving or difficult to treat low back, hip, coccyx, proximal hamstring, deep buttock pain

39 Examination Clues Neville et al (2012) Examiners achieved 100% specificity in identifying women with self-reported CPP using painful pelvic floor muscle palpation and the Forced FABER test Personal observation Pain in pelvis with MMT of hip muscles Can t get core exercises or pelvic pain with core exercises

40 Forced FABER Test

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42 Transabdominal US

43 Lit Review A literature base concerning LBP and pelvic floor dysfunction is developing

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45 Cochrane 2010, 2014, 2015, 2018 Provides support for the widespread recommendation that PFMT be included in firstline conservative management programs for women with stress, urge, or mixed, urinary incontinence

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47 Cochrane 2012 There is some evidence that for women having their first baby, PFMT can prevent urinary incontinence up to six months after delivery. There is support for the widespread recommendation that PFMT is an appropriate treatment for women with persistent postpartum urinary incontinence. It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches and in certain groups of women (for example primiparous women; women who had bladder neck hypermobility in early pregnancy, a large baby, or a forceps delivery)

48 La Rééducation Périnéale

49 LBP Literature Several studies have shown an association between back pain and UI in both men and women Finkelstein et al, Smith et al, Kim et al, Bush et al Van Wingerden et al (2013) determined that in 1636 patients with low back pain/pelvic girdle pain, 57% of women had pelvic floor complaints Eliasson et al (2008) 78% of women who were receiving physiotherapy for LBP also reported urinary incontinence Arab et al (2010) Transabdominal US indicates PFM dysfunction in patients with LBP c/w controls Bi et al (2013) Pelvic floor exercise in combination with routine treatment provided significant benefits in terms of pain relief and disability over routine treatment alone for chronic LBP

50 LBP and Pelvic Dysfunction Association between lumbopelvic pain and pelvic floor dysfunction in women: a cross sectional study Dufour et al, Musculoskelet Sci Pract April 100 female patients presenting to physiotherapy for complaint of LBP, not pelvic dysfunction 96% of patients were determined to have pelvic floor dysfunction 84% had overactive pelvic floor 67% had weakness of pelvic floor

51 Take Home Some difficult LBP cases have underlying pelvic muscle dysfunction as missing link Often don t present c/o pelvic pain Need to elicit proper h/o urinary/bowel/sexual symptoms Suspect in patients not resolving with usual treatment or if risk factors present

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