Myofascial Pelvic Pain

Transcription

1 AACP MUSCULOSKELETAL ROADSHOW Myofascial Pelvic Pain Jennie Longbottom MSc BSc MCSP MBAcC

2 Misdiagnosis is the common cause for patients to seek multiple physicians, to undergo pharmacological, psychological and surgical interventions before referral to physiotherapy. Chen & Soong 1997; Lindheim 1999; Stones and Mountfield 2000

3 Causes Rotation dysfunction between T9-T12 (Sahramm 2002) Referred neural tension from Thoracic Spine (Bannister 1998; Grant 2002; Peleg et al 1997) Endometriosis (Laufer et al 1997; Walter 2001) Biopyschosocial involvement

4 T 9

5 Myofascial meridians Myers 1988

6 Clinical Reasoning approach Identify the pain mechanism and the tissue type involved. Identify the synergic muscle activity that may reproduce pain Identify pelvic floor muscle dysfunction Pelvic floor examination is critical to define the scope of symptoms

7 Co-existence of Urological Dysfunction Stress incontinence Dyspareunia Will indicate a muscle performance impairment Urge incontinence Will indicate neural performance impairment Organ impairment Autonomic impairment Co morbidity of mechanical and non mechanical pain may be present

8 What are you looking for? Soft tissue differentiation Pain reproduction from: Muscle Ligament Contraction Activity or postural dependent pain Stress

9 Treatment Regime Correction of muscle imbalance Trigger point deactivation Re-education of faulty movement patterns Education of patient Therapeutic correction

10 Structures involved Joint impairment Referred from spine, pelvis & hips Fascial restrictions Connective tissue impairment Muscle impairment Neurological involvement

11 Pelvic impairment Hypermobility of SIJ Anterior iliac Torsion Posterior Iliac Torsion Sacral rotation Hypermobility PS Superior/Inferior glide PS

12 Muscles Involved Ilopsoas Gluteus Medius/Maximus Tight ITB External / Internal Obturator Hamstrings Gastrocnemius Piriformis Abdominal muscles Adductors/Pectineus

13 Pubic Pain Prevalence of pubic pain in pregnancy in Europe 1 in 36 Ligamentous laxity: Osteitis Pubis Ligamentous rupture Pelvic dislocation Borg-Stein J (2005)

14 Posterior Pelvic pain Pain between posterior iliac crests and Gluteal fold especially SI joints Diagnosis by positive posterior pain provocation test Palpation of dorsal sacroiliac ligament shows tenderness on palpation in patients with peripartum pelvic pain. Patrick s fabere test Elden (2005)

15 Protocol Desensitise allodynic tissues Timed voiding to reduce sensitivity of bladder wall Release connective tissue tension in pelvis Viscero-somatic and somatovisceral reflex inhibition Release trigger points

16 Muscles Involved The Adductor Mechanism

17 Adductor Brevis Adductor Longus

18 Pectineus

19 The Abdominal Component

20 External Oblique Rectus Abdominus

21 Ilopsoas Multifidus

22 Pyramidalis

23 Diastases Rectus Abdominus

24

25 ILIOPSOAS MYOFASCIAL RELEASE

26 Lund et al 2006 Pain sites weeks gestation 10 points used BL KI11 CV3 Innervation LI4 SP6 Liv2 2xweekly

27 Elden et al (2005) Pelvic girdle pain weeks gestation 17 points 10 Local segmental BL26-54 KI!! GB 30 SP 12 HJJ L4/5 7 Distal GV 20 LI 4 ST 36 BL 60 2xweekly x6 weeks Acupuncture superior to stabilizing exs alone

28 Guerreiro da Silva et al (2004) LBP / Pelvic Pain weeks gestation 12 needles KI 3 SI 3 BL 40, BL 62 TE 5 GB 30, 41 HJJ 8-12 Rx over 8 weeks Control group paracetamol and hyoscine &8% NRS in acupuncture 15% in control

29 Kvorning et al (2004) Pelvic and LBP in late pregnancy weeks gestation Liv 3 GV 20 Bl 60 SI 3 BL Ashi points at ASIS SI joint Symphasis Pubis (CV2) Periosteal pecking Control TENS, physiotherapy, SI belt 43% acupuncture group 9% control

30 Wedenberg et al (2000) LBP and PP weeks gestation 2-10 points Auricular Bl CV2 Ashi points 3x weekly x 2 weeks 2x weekly for 2 weeks Control physiotherapy VAS and PDI decreased significantly in acupuncture group

31 Research Highfield ES et al (2006) Adolescent endometriosis-related pelvic pain treated with acupuncture: two case reports. Journal Alt comp Med: Apr 1 ; 12(3): Wedenberg et al (2000)A prospective RCT comparing acupuncture with physiotherapy for LBP and pelvic pain in pregnancy. Acta Obst & Gynea Scand:79;

32 Young G (2006) Interventions for preventing and treating chronic pelvic pain and back pain in pregnancy. Cochrane Library (4) acupuncture was rated as giving 'good' or 'excellent' help more frequently than physiotherapy (odds ratio 6.58, 95% confidence intervals ) but this may reflect the benefit of individual compared with group therapy. Both physiotherapy and acupuncture may reduce back and pelvic pain. Individual acupuncture sessions were rated as more help than group physiotherapy sessions.

33 Kim (2005) Acupuncture for pelvic girdle pain in pregnancy. Alternative Therapies in Women's Health Dec; 7 (12): 93-5 Comparison of: Standard treatment (n = 130) Standard treatment plus acupuncture (n = 125) Standard treatment plus stabilizing exercises for pelvic girdle pain during pregnancy (n = 131) RCT single-blind con-trolled trial 27 maternity care centres. The participants (n = 386) were pregnant women with pelvic girdle pain who were treated for six weeks with: Assessment: VAS Concluded that acupuncture and stabilizing exercises constitute efficient complements to standard treatment for the management of pelvic girdle pain during pregnancy. Acupuncture was superior to stabilizing exercises in this study.

34 Myofascial Pain Research Baker P (1998) Musculoskeletal problems in chronic pelvic pain. An Integrated approach. Philadelphia: W.B. Saunders King et al (1991) Musculo-skeletal factors in CPP. J Psychom Obstet Gynecol 12: 87-98