The Effectiveness of Manual

Therapy on Chronic Pelvic Pain:

An Evidence-Based Review

Jessica Manley, DPTc

PT 910 Evidence-Based Practice

Spring 2012

Pelvic Floor Musculature

The Roles of the Pelvic Floor

Pelvic floor

function

Support for viscera

Spinal stability

Bowel and bladder function

Sexual function

Respiration

Gentilcore-Saulnier et al. 2010, Fritsch et al. 2011

What is Chronic Pelvic

Pain?

CPP

Pain in the pelvis or lower abdomen

Pain with sex Pain with

urination/defecation

Bowel

and bladder

dysfunction

Sexual

dysfunction

Anxiety

and

depression Anderson et al. 2011,

FitzGerald et al. 2009, Heyman et al. 2006,

Montenegro et al. 2010, Maigne et al. 2006,

Oyama et al. 2004, Figuers et al. 2010

Significance of CPP

Prevalence: 14.7% - 25% women and men

60-95% women and men with refractory CPP

$881 million to $2 billion per year in the US

Alappattu 2011, Stones et al. 2010, Montenegro 2007, Mathias et al. 1996, Tu et al. 2005

Causes of CPP

CPP Trauma

Visceral disease

Visceral pain

Mechanical abnormalities

Chronic holding patterns

Repetitive minor trauma

Pain anxiety

Alappattu 2011, Hoffman 2011, Anderson 2002, Gerwin 2002, Jarrell 2008, Wu et al. 2009

Current Treatment of CPP

Surgery

Laparoscopy

Laparotomy

Coccygectomy

Pharmacology

Hormone therapy

Tricyclic Antidepressants

SSRIs

Local injection

Botox injection

Psychotherapy

Psychotherapy

Writing in a diary

Manual Therapy

Static magnetic therapy

PFM manual therapy?

Roth 2011, Stones et al. 2010, Butrick 2009, Patijn et al. 2010

The CPP Cycle

Hypertonic PFM

Myofascial trigger points

Prevents normal resting tone

PFM dysfunction

Pain anxiety

Sustained muscle activity

Weiss 2001, Montenegro et al. 2008, Chaitow 2007

Relevance to PT

PT

Test and measure

incontinence

Toileting position

Muscle performance

of PFM

Muscle length of

PFM

Myofascial trigger point

release (MFR)

Pauls and Shelly, 1999

PFM Manual Therapy

• PFM Manual Therapy: Compression, contract/relax stretching and STM of myofascial trigger points

• Abdominal wall, back, buttocks, thighs, and PFM transrectally or transvaginally

• Thiele Massage: massage from origin to insertion along the direction of the PFM

Weiss 2001 Butrick 2009

Gap in Literature

No current reviews on manual therapy for

the treatment of men and women with CPP

Little guidance to PTs on effective treatment for these symptoms

Purposes

• Is manual therapy effective at reducing pain for men and women with CPP symptoms?

• This is a foreground question.

Primary Purpose

• Is manual therapy more effective than a control or comparison group at reducing pain for men and women with CPP symptoms?

Secondary Purpose

PICO

P

• Acyclic

• Inflammatory or non-inflammatory pelvic pain

• Lower abdominal pain

• Urogenital pain

• > 1 month

• Not associated with pregnancy

I

• PFM manual therapy

• Thiele Massage

C

• Control

• General, non-specific massage

• Counseling

• Short-form wave therapy (magnetic)

O

• Visual Analog Scale (VAS) for pain

Hypotheses

• Manual therapy is not effective in reducing pain in patients with CPP

First Null Hypothesis:

• Manual therapy is an effective treatment for reducing pain for patients with CPP

First Alternative Hypothesis:

• Manual therapy has no effect on pain reduction when compared to a control or comparison group

Second Null Hypothesis:

• Manual therapy has an effect on pain reduction when compared to a control or comparison group

Second Alternative Hypothesis:

Expected Findings

10-20 articles on manual therapy for CPP

Statistically significant reduction in pain with manual therapy interventions

Statistically significant difference in pain with manual therapy interventions when compared to control or comparison groups

Methods: Criteria

Inclusion Criteria

• PFM Manual therapy

• Outcome measurement of pain with the visual analog scale (VAS)

• English

• Human studies

Exclusion Criteria

• Incorporation of other therapies (chiropractic manipulation, drug therapy, surgery, dry needling)

• Perinatal subjects

• Case reports

Methods

Databases searched

• PubMed

• Cochrane Library

• CINAHL

Search terms

• Thiele massage, physiotherapy, manual therapy, physical therapy, trigger point, or myofascial and coccydynia, perineal, pudendal neuralgia, prostatitis, chronic pelvic pain, pelvic floor, pelvic pain, levator ani, interstitial cystitis, coccygodynia, or sexual dysfunction and pain.

Methods: Statistics

Analysis of reduction in pain via VAS:

• Single group effect size

• Two-group effect size

• Q statistic with inverse variance for weighting

• 95% confidence intervals

Results: PRISMA Diagram

A secondary reviewer confirmed that the studies met the inclusion criteria

Results: Primary Articles

Author, Year Type of Study Level of

Evidence

FitzGerald, 2009 Single-Blind RCT 2b

Maigne, 2006 Randomized Case Control 3b

Heyman, 2006 Randomized Case Control 3b

Anderson, 2011 Case Series 4

Oyama, 2004 Case Series 4

Montenegro, 2010 Case Series 4

Figuers, 2010 Retrospective Case Series 4

Results: Population

Study Patient

Population Age N Diagnosis Duration

FitzGerald, 2009 Females,

Males 43 44

IC/PBS

CP/CPPS <3 years

Maigne, 2006 Females,

Males 45 100 Coccygodynia 13 months

Heyman, 2006 Females 34 44 CPP 29 months

Anderson, 2011 Males 48 116 CP/Orchialgia 4.8 years

Oyama, 2004 Females 42 13 IC 5-14 years

Montenegro, 2010 Females 36 6 CPP >6 months

Figuers, 2010 Females 52 5 CPP 13 years

Results: Population

Patient Characteristic Average Across Studies

Males 45%

Female 55%

Age 42.9 years

Symptom Duration Range 6 months to 14 years

Results: Intervention Study Intervention

Frequency/Duratio

n Follow Up

FitzGerald,

2009

Manual stretching PFM,

MFR of PFM 10 visits, 30-60 mins 12 weeks

Maigne, 2006 Manual stretching PFM 3 visits, 5 mins 12 weeks

Heyman,

2006 Manual stretching PFM 2 visits, 5 mins 4 weeks

Anderson,

2011 MFR to PFM 5 visits, 60 mins 4-6 weeks

Oyama, 2004 Thiele massage 10 visits, 5 mins 6 months

Montenegro,

2010 Thiele massage 4 visits, 5 mins 5-7 weeks

Figuers, 2010 MFR to PFM 3-15 visits 4 weeks

Single Group Effect Size for Pain VAS

Q Statistic: 35.67

-1.28 (-1.93, -0.63)

Random Effects

Model

Statistically

Significant!

Two Group Effect Size for Pain VAS

Q Statistic: 14.28

-0.72 (-1.44, 0.004)

Random Effects

Model

Not statistically

significant

Discussion

Able to reject first null hypothesis!

• Manual therapy is effective

• Effect size is large

• Clinically crucial effect

Cohen 1988

Discussion

Unable to reject second null hypothesis

• Manual therapy is not statistically effective as an intervention when compared to control groups

Clinical Significance

• Change in VAS: Decreased by 2.56 points

Single group effect size

• Change in VAS: Difference between groups of 1.77 points

Two group effect size

• 1 point change on 0-10 scale

MCID in endometriosis

Gerlinger et al. 2010

Two Group Effect Size for Pain VAS

Q Statistic: 14.28

-0.72 (-1.44, 0.004)

Random Effects

Model

Not statistically

significant

Current Treatment of CPP

Surgery

Laparoscopy

Laparotomy

Coccygectomy

Pharmacology

Hormone therapy

Tricyclic Antidepressants

SSRIs

Local injection

Botox injection

Psychotherapy

Psychotherapy

Writing in a diary

Manual Therapy

Static magnetic therapy

PFM manual therapy

Roth 2011, Stones et al. 2010, Butrick 2009, Patijn et al. 2010

Harm/Adverse Events

4 articles mentioned adverse events

• Increase in pain from manual therapy

Potential harm of other interventions vs. manual therapy

• Surgical complications

• Medication side effects

Cost

None of the articles specifically address cost

No direct cost increase

• Training for PTs in PFM manual therapy

• Feasibility at a clinical site

Improvement with brief duration of treatment

• 4 of 8 studies used 5 min treatment sessions

Implications for Clinical Practice

Address this issue!

• 70% of women diagnosed with endometriosis report that at least 1 physician has claimed their symptoms were due to psychological disturbance

What specifically should YOU do?

• Ask patients about pain in this area

• Possible questionnaires: McGill Questionnaire

• Refer as necessary!

Roth 2011, Stones et al. 2010, Montenegro 2007

Limitations

Articles in English available to author

High Q statistic, heterogeneity in articles

• Different manual therapy techniques

• Different diagnoses

Lack of functional outcomes

Pathogenesis of CPP is poorly understood

Future Work

More studies on PFM manual therapy

• CPP diagnosis

• Functional outcomes

• Intervention frequency/duration

Conclusion

PFM manual therapy is a low risk, effective intervention for pain associated with CPP

Thank You!

• Amy Selinger, PT, DPT, OCS

• Jeannette Lee, PT, PhD

• Diane Allen, PT, PhD

• Brianna Pickering, DPTc

• Justin Trumbull, DPTc

• USCF/SFSU Faculty

• UCSF/SFSU Class of 2012

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Questions?