The Role of Physiotherapy in Chronic Pelvic Pain. Maree Frost Pelvic Health Physiotherapist GP Conference, August 2015, Christchurch

Transcription

1 The Role of Physiotherapy in Chronic Pelvic Pain. Maree Frost Pelvic Health Physiotherapist GP Conference, August 2015, Christchurch

2 Apologies Sorry I could not talk to you in person.

3 Background 15 years experience Pelvic Health Physiotherapy Established Pelvic Floor Physiotherapy Outpatients service at Christchurch Womens Hospital Now full time private practice: pelvic health men and women

4 Traditional Pelvic Floor Physiotherapy Indications: Urinary and faecal incontinence, urgency Pelvic Organ Prolapse Management: Pelvic Floor Muscle Strengthening / biofeedback Corrective biomechanical / structural deformities Corrective exercise

5 New developments: Chronic Pelvic Pain Last 20 years, internationally Last years, New Zealand growing in skills Commonly treated conditions: Painful bladder syndrome Vulvodynia / vaginismus Pudendal Neuralgia Post operative pain (adhesions) Endometriosis related Chronic non-bacterial prostatitis Musculo-skeletal disorder or trauma pelvis / spine Coccydynia Anismus etc

6 Physiotherapy Management Connective Tissue Mobilisation Myofascial trigger point release Neural Mobilisation Pelvic Floor Muscle lengthening Correcting biomechanics What does this mean?

7 These techniques Help to restore normal function and integrity to the connective tissues. Connective tissue surrounds muscles, membranes, fibres and all systems including the nervous and musculoskeletal system Gives our body shape and support Just about all chronic pelvic pain patients have connective tissue restrictions: Pelvic Floor Bony Pelvis Abdomen Thighs Gluteals Errector Spinae

8 CT restriction - effects Globally Poor posture (protective pain brace ) Poor breathing pattern (driving Sympathetic Nervous System dominance) Poor movement behaviours Poor motivation Locally Tenderness Hyperalgesia Trophic changes Muscle atrophy and shortening

9 CT restrictions A result of Visceral referral pain (visceral-cutaneous reflex) Inflammed peripheral nerve Joint restriction Myofascial Trigger points Last 20 yrs research has observed the interaction between muscle, skin, internal organs and the central and peripheral nervous systems

10 Goals of CT mobilisation Improved circulation Restore tissue integrity Decrease ischaemia Reduce chemical irritants Eliminate adverse reactions in viscera Decrease adverse neural tension peripheral nerve branches

11 To be effective Patient needs to be motivated and willing to make positive lifestyle changes Positive posture, positive breathing, positive movement Healthy diet and sleep / exercise Patient needs adequate pain control. If too centrally sensitised, this requires the Pain Specialist to assist in modulating pain. Sessions vary depending on case: Weekly to fortnightly for the first few sessions then monthly for 3-6 months.

12 This is the best job! And at times the most difficult job! It is rewarding to help people move towards restored function and fulfilled lives. It is the best gift for our patients

13 The Role of Psychology in CPP Introductions The role of anxiety and avoidance Pain sucks! The role of mood Relationship issues the push-pull dynamic Treatment Engagement issues Cognitive-behavioural approaches Third wave approaches Mindfulness approaches, Acceptance and Commitment Therapy Working with the couple and relationship

14 Introductions Clinical Psychology training background Worked in mental health and psychiatric consultation since 1996 Completed Advanced training with Sex Therapy New Zealand in 2013 Practice from a predominantly cognitive behavioural perspective

15 Anxiety and Avoidance It is normal to want to avoid pain Scales of Justice what is your learning history in terms of sexual pleasure (or otherwise)? History leads to present day expectations Expectations lead to Anticipatory Anxiety Anxiety leads to pain = A Vicious Cycle of Pain, Anxiety and Avoidance

16 The Role of Mood Strong empirical relationship between chronic pain and low mood Low mood and clinical depression cause greater perceived pain intensity, and greater suffering Psychological treatment (CBT) for depression are as effective as antidepressants, for mild to moderate depression, and is also effective in combination with antidepressants

17 Relationship issues the push-pull dynamic Low desire is the bread and butter of presenting problems in Sex Therapy When there is a mismatch of Sexual Desire, a pushpull dynamic typically develops This results in a withdrawal from affection and physical touch generally, and impacts negatively on the relationship generally

18 Psychological Treatments As in Chronic Pain generally, engagement in psychological approaches can be a challenge Treatment is individually tailored: Copulation vs intimacy: non-demand pleasuring Identify anxieties, and knowledge and skills deficits Is sexual problem really a broader intimacy problem, based on negative attachment experiences, and/or trauma? (Salisbury, 2008) Cognitive behavioural approaches Education Increase communication- become an erotic team Semi-structured sexual exercises to facilitate changing sexual attitudes, behaviour and feelings

19 Third wave approaches Mindfulness approaches, Acceptance and Commitment Therapy These approaches have demonstrated effectiveness with chronic pain generally Concept of detached mindfulness observing thoughts rather than engaging with them ACT challenges assumptions that life should be pain-free, and encourages patients to identify values and set goals in order to live the best life possible in spite of their pain problem, rather than put their lives on hold until the problem is cured

20 Working with the couple and relationship Sexual Pain is a couple and relationship issue Communication is key Our culture often does not support sexual openness and communication A focus on Pleasure rather than Performance decreases anxiety Broaden the Sexual Repertoire

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22 Take-home Message Chronic Pelvic pain is best addressed from a biopsychosocial perspective Psychology has much to offer in the management of Chronic Pelvic pain, and can decrease suffering and relationship distress

23 References and Links Salisbury, R.M.(2008). Out of control sexual behaviours: A developing practice model. Sexual and Relationship Therapy. Volume 23 (2),

24 The Role of Dietetics in Chronic Pelvic Pain Stephanie Brown New Zealand Registered Dietitian Women s Health and Gastroenterology

25 Background Paediatric Gastroenterology Dietitian at Christchurch Public Hospital Women s Health Dietitian (Maternity and outpatients) at Christchurch Women s Hospital Private Practice Dietitian in Women s Health at COGA and Intus Digestive and Colorectal Health

26 New developments: Chronic Pelvic Pain The low FODMAP diet Commonly treated conditions: Endometriosis Polycystic Ovarian Syndrome (PCOS) Irritable Bowel Syndrome (IBS) Diverticular Disease Pre and Post-operative dietary requirements etc

27 Dietetic Management What are FODMAPs and what is the FODMAP diet? FODMAP is an acronym for Fermentable Oligo-saccharides, Disaccharides, Mono-saccharides And Polyols. Oligosaccharides, di-saccharides, mono-saccharides and polyols are all types of sugars that are naturally found in foods. Common places where FODMAPs are found Oligo- saccharides Di-saccharides Monosaccharides Some vegetables Lactose Fructose and fruits Dairy products Some fruits and Legumes, chickpeas vegetables Wheat, barley and Honey rye Polyols Sorbitol Mannitol Some fruits and vegetables Some artificial sweeteners

28 Diagram: What do FODMAPs do in the Body?... (Reference: MonashUniversity)

29 Effectiveness High intake of FODMAPS can exacerbate: diarrhoea, abdominal bloating, abdominal pain, abdominal cramps, oesophageal reflux, nausea and constipation. Trialing the elimination and systematic reintroduction of foods containing FODMAPs can improve symptoms. Foods that are not well tolerated and need to be eliminated / eaten in small quantities can be identified. Whilst this is not curative, it is the new Gold Standard in dietary intervention for conditions that attribute to chronic pelvic pain with a high success rate and, Based on sound science!

30 Dietetic / Nutritional Management Why should a Dietitian be involved? Closely monitor adequacy of nutrition Provide support and clarity around food intake / choice Ensure unnecessary over-restriction of foods Manage expectations and answer questions Review the patient for the reintroduction phase Specialised food plans are necessary in instances of different dietary requirements (cultural, pregnancy, food allergies etc.)

31 Take Home Message 1. FODMAPS play a role in the exacerbation of symptoms associated with chronic pelvic pain. 2. The low FODMAP diet is the new Gold Standard of dietary treatment. 3. Ensures the patient can help themselves manage their symptoms. 4. Dietitian involvement is important because there is a lot of misleading information on the internet and elsewhere! Thank You!

32 Chronic pelvic pain quiz Please answer questions there is wine to be won!

33 How many people in NZ suffer from chronic pain?

34 Pain Epidemic 1 in 6 New Zealanders suffer persistent pain Chronic pain is the 3 rd biggest cause of illness related disability for New Zealanders Only 5% see a pain specialist Consider a MDT approach

35 Define chronic pelvic pain

36 Chronic Pelvic Pain: Definition CPP is nonmenstrual pelvic pain of at least 6 months duration that is severe enough to cause functional disability or require medical or surgical treatment BUT target acute persistent pain this is a window of opportunity to prevent chronic pain.

37 Why do we need MDT to manage pain patients?

38 Chronic pelvic pain (& perineal) pain These patient cause a high degree of frustration 1:6 are characterized as difficult, need a strategy to deal with them otherwise 12x more likely to have professional burn out. Often complex and have multiple perplexing functional symptoms Require long term management.

39 What a pelvis looks like at laparoscopy

40 Endometriosis has many appearances

41 Which woman has more pain?

42 Common pelvic pain misconceptions That if there is pain that, it should be present at laparoscopy No reliable correlation between the amount of endometriosis and the amount of pain (Vercellini P Hum Reprod 2006)

43 Common pelvic pain misconceptions 2 If something is found at the time of laparoscopy then that is the cause of the pain Just because an abnormality is found, does not mean that it is the cause of the pain. There are many pains you cant see.

44 What makes pelvic pain different? Periods or endometriosis are early drivers of pain Estrogen is a nerve sensitiser (monthly aggravator of pain) Invisible pain from a young age, anxiety, social stigma, fear

45 Pelvic muscles get tighter

46 Nerve pathways get sensitized

47 Life time impact of pelvic pain Pain is an emotional experience Fear factor Social isolation and withdrawal Reduced activity

48 Getting Better

49 Management Plan Stop the problem Reduce muscle spasm and bowel dysfunction Manage nerve pathways Get back to life by learning new coping skills

50 Management Plan Keep active with things you enjoy Exercise for healthy body function Regular sleep Keep working and active-you have better things to think about than pain Reduce fear-pain is not dangerous See a pain specialist AVOID REGULAR OPIATES

51 Management plan Minimize periods and period pain Voltaren, OCP, progesterone tablets Constipation Movicol (soft bowels without excess wind) Painful sex, aches Regular exercise, stretches, pelvic physio, Anxiety and low mood Exercise, psychologist, enjoyable activities