false
Catalog
AUGS/IUGA Scientific Meeting 2019
Multi Disciplinary Assessment and Treatment of Chr ...
Multi Disciplinary Assessment and Treatment of Chronic Pelvic Pain and Sexual Dysfunction - Chronic Pelvic Pain
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Video Transcription
So, thank you very much to everyone. Thank you for coming along to this session. My name is Angie Rantel, and I am the Trust Group Member A Different Trust in Wales with the UK Government. It is interesting that we ask the first of these three sessions for the Different Professional Health Tract, especially for the physiotherapists, the workers, and anyone who wants to come in. We have three sessions for the meetings. The first is at the moment, we have one after the day, and one after the day on Britain day. We would also like to announce any employees and diners in to come to our Different Professional Health Association in Wales which meets on 8th all on Britain's day to look at how the associations can change on for the work and what we need. 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If you remember, on a general level, on a personal level and at a social level, so trusts campaign and the problems are the abilities, therefore the abilities and these hordes. So what we see is that they have difficulty separating between vaginism and dysparinism. So from the general point you can understand that, but it is different from the general campaigning. Well, for example, you have the opportunity and the difficulty you get on the service, or you don't, and that's the difficulty. So, on the general numbers, something completely different. We have to try for us to also say the same terms and to understand ourselves how to work on that, because effective for behaviors, difficulty makes the facto such a thing difficult. I told you about the disability. And actually, when we are going to treat those patients, then we can go along with the pain contingent aspect. So say, OK, we understand it. Giving painkillers, giving this, giving that, giving relaxation. But also, you can say, no, it is activation contingent. How can we now work with our partner for muscles to try to diminish this problem as such? And this is a very important thing. And like I said, the central parts are very involved, especially also the limbic system and the index. So it is not only focusing on pain reduction, but for sure, also to try to decrease the disability of these patients. And the same goes for restriction and participation. We need each other. And we should ask the patient what the patient needs and give the patient a perspective on the more mortal treatment part. When you look to pelvic floor dysfunctions, when we look at the muscles as such, we have overactivity of the pelvic floor muscles, underactivity, or a coordination problem. And this frontal pelvic pain goes along with stress. And in fact, what we said, this can lead to pain. But this leads to muscle spasm, muscle tension, pressure on the nerves, and trapping of nerves. We use this activation in the local parts. Muscle shortening of the shins, as I said. Restricted movement, and then the trigger point, and as such. Again, a vicious circle. And physiotherapists are trained to work with this. And this type of patient, this frontal pelvic pain, needs a lot of assessment. It really needs to be an adaptive and adaptive way of looking to this patient. Because many of these patients have that frontal pelvic pain. You have to be aware that it has also had a past physical abuse, or sexual abuse, and things related to this. So it's very important also to look at this. So the physical therapist who is motivated and says, I can do this, think about it, whether you really can do it. Because you have to look to this alone algorithm. You have to ask yourself, and hire the person to do this. You have to legitimize that you are skilled and experienced enough. And if not, you have to refer to somebody else, because you are limited. And it's very necessary to open up for further discussion and evaluation with your team, and especially with your pain nurse. At the meeting of the president, releasing the assessment of the pain that the president brought, that the patient should be centered. So here we have a possibility to center the patient and work together with the patient to develop a treatment plan as such. What can we do as physical therapists, physical exams, and as I said yesterday in the meeting, that I think that the word physical therapy is a wrong word, because it's not only a therapist, it's not only therapy, it is also diagnostics. Not the medical diagnosis, but the diagnosis, the assessment, and we do, like I've shown you now, two times, I think, and on local level, on the personal level, and on social level. And as such, we get our parameters for our body, for our muscle pain, or for our bio-condemn, or for our trigger point things. And so what we do, we look at the presence of pain externally and internally, for those that have, again, skill and experience with this. So not every physical therapist in every country is allowed to do so. In my country, about physical therapists, there's a specialization of three additional years. And it means that we have to, at that moment, that we have to set the goal for, yes, that we have to be trained, we have to be examined, we have to be registered, and we have to be in the group, as such. So, don't do this, these techniques, and especially not in patients if you are not skilled enough to do so. What we do, we look for aledinia, for hyperalgesia. Everybody knows what is aledinia and hyperalgesia. Aledinia means that when you are going to touch something that was actually not painful as such, but now because of the sensitization, peripheral and central sensitization, it is going to hurt now, that is aledinia. And hyperalgesia means that there is aggravating pain already, and so it's something else. So we do a neuromuscular skeletal exam. We need to learn the bones and the gluteals. And in our courses, we have an assessment, a whole structure of how to assess the pelvic floor. Also, the functional way, a functional assessment, and we have to be sure that there is not the eye, eyes, hands, as such. And what we do is that we not only do the voluntary contractions, but also involuntary contractions of the pelvic floor muscles, as such. The time is not sufficient to go too deep into this, but we also look to the abdominals and gluteals because we see the relationship with the viscera are involved, as such. Also, we look to entrapment and myofascial trigger points. For sure, the activity is very important after the contraction, for instance, if the patient is able to fully relax, and is that complete, incomplete, absent, or delayed. Things that matter, for sure. Also, the functionality of this pelvic floor. So, the relaxation of the pelvic floor muscles, as I just said, we do some tests, and also the dispersion, as such. When we look to the physical examination techniques, then we have seen that our myofascial targeted pelvic floor physical therapy assessments, and what we see as a conclusion of this recent paper is that physical examination methods to eliminate pelvic floor muscles, which are the presence of myofascial pain, varied significantly. So, there is a lot out there in scientific papers where we agree that we disagree about how to assess the pelvic floor, as such. That's why we should have a structure, and that's why we make an assessment paper with our special interest group, pelvic rehabilitation, that we want to have published in a short time. We are discussing how to do and how to perform on this, so you will be notified in due time about this. The development and standardization of a reliable and reproducible examination, especially also in this field, is absolutely more important and very important to do so. When we look at the interventions, I will not go into each of them separately because of the time. Again, information and education, very important, always a starting point. We say that our, let's say, assessment and therapy is like an egg diamond. So, here is the egg diamond. And so, here is history taking a lot of questions. All those questions are met. Going to functional tests, going to digital examination, inspection, observation, palpation, coming to an evaluation and analysis, and then coming to our parameters for our therapy, which might be, for instance, pelvic floor surgery and rehabilitation, but maybe we need biofeedback in those patients that are not aware how to do pelvic floor, but they should be aware. I'm so honored that we can do this kind of therapies. So, respiration exercises, global, like Jacobson progressive, Jacobson realization techniques, pelvic floor muscle training, I'll come back in a minute to this, myofascial release, myofascial techniques, massage, stretching. So, joint mobilization, trigger points, biofeedback, a lot of things like this. Pilots, the last one I put here, actually, I would not recommend them too much, because when you look to these pilots, they are actually meant for people with women with fibromyalgia, and when you put this in, there's a biomechanical, there's a mechanical influence in that part, and actually, like I said, psychological, emotional, things are related. Women dislike it very much, so you have to be very careful when introducing this into the vagina, and so, it's not so easy to perform this. I'll just give you one small example. I'm in time, still? Okay. So, you see here, I'm sorry for the people in the back, but it is a technique where we do, for instance, when there's a scar tissue, I saw this morning beautiful movies about a recent restoration of the perineum, so there are a lot of scar tissue when you have not the idea of doing, because of this, first, you have to do pelvic care. The physiotherapy, for instance, you can do a lot of techniques, easy-going techniques to try also to influence the scar tissue, the, let's say, entrapment of nerves, also, different techniques, so you can do the steroid technique, and so, there are a lot of possible techniques that you can try to do this area. So, pelvic muscle training, and this is a very special thing. We are planning in our special effort group to have a pelvic muscle training paper, and a really, a paper that collects all the ideas about pelvic muscle training, because as a medical doctor, you see the patient in front of you, and you have to motivate the patient to go to the physiotherapist, but do you really know what pelvic muscle training means? Does the patient know that? Is that necessary that there is some information about it? I would say, yes, it's very necessary, and actually, that's why we developed the 5F concept, which means that when you have to use your pelvic floor, you first have to know what pelvic floor is, but I may ask you to do, and hope you will cooperate with me, now, try you, as physicians, try now to contract the pelvic floor. Now, hold your pelvic floor, and then contract your abdominal muscles while holding the pelvic floor, inside, outside, holding the pelvic floor still, and now relax the pelvic floor. Please do. Contract the pelvic floor. Now, hold it, contract your abdominal muscles, relax your pelvic floor muscles, holding the pelvic floor still, and now relax your pelvic floor. You see how difficult that is? It's extremely difficult, and patients, they don't know, because when they hold the contracting, and they have, for instance, pain that may provoke pain, or they have incontinence that may provoke the incontinence, because they are pushing instead of squeezing, and in the lifting of the pelvic floor, which is necessary, and for relaxation, completely disabling, so, finally, this is the one thing, not feeling the pelvic floor, so, when I do this, you say, oh, there is no inflection, and I'll give you relaxation, but, how do I do now? Okay, yes, I'm contracting my pelvic floor, I'm relaxing my pelvic floor, but you cannot see it, so that's very important. Third step, force. Force means, in most patients, more relaxation, more coordination. Explosive strength, endurance, strength, these things, also important, but this is all on the training table. Would you be satisfied with this? No, you have to go to different positions and configurations, and then do functional training, and now I come to the point where your patients come back to you, please, doctor, don't send me back to physical therapists, because that does not help. You hear that. Why do we hear that? Because many physical therapists do silly exercises, but I want you to learn how to swim. Then, maybe I'll take you as a victim for me, I want you to learn to swim, and I say to you, do this, and now this, and you do that every day, okay? He says, that's fine, we don't want to do that, and next time you come to me, I ask the same thing, and you do that again, but the next week you come back, and I ask you exactly the same thing, you will say, Patrick, what is this? I want you to learn to swim. Okay, let me go to the water, shallow water, more, more, more, and up to here, and at a certain moment, you're still on the go, right, you cannot swim, at a certain moment you can swim in the pool. Does it mean that you can swim three kilometers? Sure not, you have to go to the river. If you go to the river, you can swim three kilometers. Can you swim three kilometers your whole life? No, but you can swim an awful few kilometers, so you have to train your whole life, that's risky, powerful muscle training, parameters, things, and programs, that matters, and that is a big problem. Many locations, it is not like that. So, to motivate women, you have to do fun activities, formal activities, especially with women that have delivered a baby, and formal activities, I don't want to lie to you, but play tennis again, and also fitness activities, and then, women will be motivated, doctors will like to, because it means, now I am getting something that is better. And especially in those locations, we need skilled physical therapists, how to do this powerful muscle training, and that is very important as such. So, we have made a paper already on this, and this has been published in 2017. There will be a big paper, I hope, and a teaching module on such, because we need it in our multidisciplinary association. Myofascial techniques, EMG biofeedback, you can see here, this is, let's say, the result of the powerful muscles, and there is another electrode, certain superficial electrodes, that are capturing the activity, the motor unit activity of the abdominal muscles, and you see, for instance, that this is very, let's say, active, overactive, and it means that it is before, and when we do the myofascial techniques, you can see that the biofeedback has an aggravation, agnostic aggravation tool, that it is going to diminish, and that is fantastic as such. So, when we look to this, and then, for those that say trigger points don't exist, there was a fantastic paper, myofascial trigger points of pelvic floor, associations with neurological pain centers and treatment strategies. We now know that chronic pelvic pain can have urgency, frequency, can have IBS, et cetera, so that's not so surprising, but 85% suffering from neurological, colorectal, and radiological pelvic pain centers, they have this kind of contraction knots, or myofascial trigger points, and you see this, I can find, I can deny, by high tone pelvic floor muscle dysfunction. So, the proof is there, it is there. There are trigger points, and it has muscle spasm, and in the beginning I said, from evidence-based theory to clinical practice, it is all there, and this is a study from Maltman, which shows that the interrelationship between pelvic pain centers, and you see that myofascial trigger points and pelvic floor dysfunctions, that it is all interrelated with each other, leading to pelvic pressure, urgency, incomplete emptying, hesitations of urine, conflagration, hysteremia, and also sexual problems with ejaculation. So, it is all there, the proof is there, the evidence is there, now if you were according to it, and to make it very nice. Where to find those, that is the mapping that I said, you see here, the females, and this is the males of females, I don't know which one is, no, left and right, I would say this is the men, that is the women, but by looking here, you can see a little bit different, and we have, in all these masses, we know exactly where there are those most common trigger points, and you can see them right here, study it, and you will know more about it as such. We have different techniques for myofascial pelvic pain syndromes, to inactivate trigger points, which transfers palpation, flat palpation, pin-cell palpation, we all have filmed this, we have movie on this, and we can instruct you if you want, on this kind of things, or if there's a therapist among you who is interested, come to me, and we will share it with you. And those myofascial techniques are significantly better than whatever massage is there. Current myofascial literature, what we see, is that the authors of this critical overview of current myofascial pain literature, they concluded that loaded and weak muscles are more prone to an energy crisis. So it does not mean that there has to be an interruption of the motor unit, so the connection between the neurons and the mass of tissue, there's not only damage that you did, it can also be because of just overload, just weakness, because of the trauma that you have, for instance, a giant lady with ulcer trauma, so that you have suffered, and it might be because of this that you develop those trigger points, and we have to find more studies to look at this point as such. In the literature on chronic chronic pain, many, and because of the time, I'm not going to incite all of those, but these are only the recent papers that I have selected, and I have selected them on their value as such, and what we see is that there's strong evidence of the efficacy of physical therapy as part of the modernist therapy for drogoephrenia, so that's one, and that's 2014, and then we have in 2015, pelvic physiotherapy improves sex life and decreases pain as good as injections, and so I would say injections have also maybe their side effects, that the physical therapy should be treated as such, because also there is evidence for that, and then comparing the effect of physiotherapy with surgery on sexual functions on women with topical muscular dysfunctions, then we saw that also physiotherapy here showed to be an appropriate method, without saying that surgery would not help, that it might be worthwhile to try to do this therapy as such. Then our own study that was published last year because of the Ullrich-Umsen lecture that I gave two years ago, Physiotherapy for Topical Pain and Female Sexual Dysfunction, an untapped resource, and the conclusion here is, because of the holistic approach, physiotherapy can contribute significantly to the multidisciplinary assessment and treatment of chronic pelvic pain and female sexual dysfunction. Here is a study that we have done, have published this year, this is our theory in France from the University of Paris in Iran, and what we saw is that pelvic floor reputation in women with dyspareunia, a randomized controlled clinical trial, that pelvic floor reputation is an important part of the multidisciplinary treatment approach to dyspareunia. The different algorithms that we used had significant results as such. You see here how this develops, I will display you the details. And for sure, like we always have, we need more study, for sure. We are going now to publish the third edition of this book, it has to be released in January 2021, the evidence-based physical therapy for the pelvic floor. There will be an extensive chapter also on chronic pelvic pain related to pelvic physiotherapy, I will recommend it at that time to you. Is physical therapy the holy grail? For sure not, but it is worth a trial because of all the things I have said before. The last word is always to the patient, and so we are going to show you something about the patient. The same patient I saw, so you cannot make the movie now. I was very worried about this now, because I didn't know the pelvic floor. I won't do that, because there are four hours. Four hours of investigation, physical therapist, a lot of exercise and massage when you are at home, my energy is back, I can make new friends again. I would absolutely recommend this therapy to anyone who has similar problems. Something profound here, especially in this room, physical therapy is a proper assessment, a proper therapy. We have a view there, and I would really hope that you, as physical therapists, can contribute to our novel disciplinary approach, and that we can do part of the novel, let's say, approach of chronic pelvic pain. Thank you very much for your attention. Thank you. So we've got about 10 minutes for questions, if people would like to. Please, in the back. You can come to the mic, please, to the bottom. Just want to know, what are your thoughts on over-the-counter, more conservative treatments like TENS, or GD patches, or, I don't know, in their efficacy? Again? I wanted to see if you could share any comments on the efficacy of over-the-counter treatments like TENS devices. TENS devices? Yeah. Okay, sure. Actually, inactive stimulation has many variations, and one of them is TENS. And it is, as such, let's say, a passive treatment for patients, and there are, for sure, patients that are very well-helped with TENS. On the other hand, I would, that's my, let's say, preference, I would go for the active, like you said, active activation contingent, and not incontingent first, also. And it may be common for this, when you want to have something at home, for patients that are having, also, communication therapy, also, therapy like this. I would go first with this, and I would be not my first recommendation, but I think it might work. Second thing is that we lack evidence in this area about this now, and so the things that I can recommend are only from teams of people, and maybe there are people in the audience that have very good experience with that, as such. And then, the other thing is, I would not go too long for it, because you cannot go all along doing the same thing, because there's also activation, there is also that people are not going to act like they should, but for those that have no patient, I have patients that have used it, and are very pleased with it, and so I cannot say, I'm not sure that it's not done enough, but there are people that have used that. Please. Well, I'm covering this, sorry. Just two points. Lots of information, and a very short period of time. I'm sorry for that. But, one point, according to physiologists, a spasm is an electrogenic contraction that cannot be voluntarily reversed. So, stating that a pelvic floor patient has a pelvic floor spasm, means they're not urinating or defecating, and that's not the case. So, it's technically not a spasm. The other point is, muscles that have trigger points in them do not have elevated ENG activity. Only the actual trigger point has elevated ENG activity. The rest of the muscles are normal, fine. You are completely right. In both of those comments that you made, first comment about the spasm is that, in the literature that we see, is that sample sensitization can lead to muscle spasm. That's what I quoted as such. And we see that we use the term spasm in all kinds of overactivity, for instance. We also have difficulties in the terminology differentiating between hypotonicity and overactivity, because hypotonicity is actually a viscoelastic element and a contractile element, while overactivity is mostly the overactive component. I agree with you that this is what is spasmed. And your second point is also not very clear, because when you have trigger points as in other, let's say, physiological appearance, I doubt that that's going to become important. Thank you. Thank you. I just wanted to know your opinion on the role of pharmacotherapy for muscle relaxation in combination with physical therapy, like patients who respond well to violent suppositories per day, like keeping them on that would eventually resolve the issue, or? I think that it would be fair to say that in pharmacophology, there has been fantastic studies done also in this area to try to find the most optimal solution for patients with, for instance, with overactivity, like this Bayesian patient sample that are peripherally orientated. So it would not be fair to say, oh, you have to do physical therapy instead of pharmacology. What I just want to say is it might be that pharmacology has its side effects, maybe that people just use it for a longer time, that it is going to diminish its effects. As I said, physical therapy leaves all the other options open, and you can start with this and try how this would work. For sure, it's also a practice to try to make a combination of it, and then to see whether that would be better as Pila-1, but we have to study some of this, and as far as I know, and I have to be reliable in this, there are no studies so far showing that the combination is better than Pila-1 in this kind of patients, which is actually a heterogeneous group of patients. Did that answer your question? Thank you very much.
Video Summary
The video is a lecture given by a speaker named Patrick Devylde on the topic of physical therapy for pelvic pain. He discusses the role of physical therapy in the treatment of pelvic pain and gives an overview of various techniques and approaches used in physical therapy for this condition. He emphasizes the importance of a multidisciplinary approach and highlights the need for skilled physical therapists who are knowledgeable about pelvic floor health. The speaker also mentions the use of over-the-counter treatments such as TENS devices, but acknowledges that more research is needed to determine their efficacy. He concludes by suggesting that physical therapy can be a valuable part of the treatment plan for pelvic pain and encourages further research in the field.
Asset Caption
Bary Berghmans, PhD, MSc, RPT
Keywords
Patrick Devylde
physical therapy
pelvic pain
treatment
techniques
approaches
multidisciplinary
pelvic floor health
research
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