Chronic Pelvic Pain: Pelvic Floor-Specific Evaluation and Manual Approaches

Abstract

Musculoskeletal chronic pelvic pain (CPP) is characterized by soft tissue dysfunctions and trigger points in the abdominal wall, lumbar region, pelvic girdle and floor. Before starting a manual practice or strengthening program, the pelvic floor muscles are evaluated with an intravaginal examination. In CPP, pelvic floor muscles are generally overactive and contain tight bands and trigger points. Since the treatment of the pelvic floor, whose muscle tone is overactive or hypoactive, differs considerably, the treatment program should be planned according to the examination findings. Physiotherapy is included as a treatment option for CPP in guidelines published by international associations and independent reviews. Although manual therapy practices do not have the level of evidence to create a consensus, it provides a promising alternative for treatment in such a complex chronic pain syndrome. The literature shows the effects of combined use of ischemic compression, myofascial release, and post isometric relaxation techniques in the pelvic floor; trigger point deactivation in the abdominal wall and pelvic girdle; and the Thiele massage. Manual therapy practices should not only be limited to the pelvic floor, but also the abdominal wall, pelvic girdle, and lower extremities should be included in the treatment program. Additionally, posture, malalignment, and respiratory patterns should be considered. Manual therapy practices, by combining with appropriate exercises and selecting patients showing indications; may play a key role in the treatment of musculoskeletal CPP.

Keywords

• Chronic pelvic pain
• Ischemic compression
• Manual therapy
• Pelvic floor examination
• Trigger points
• Thiele massage

Kronik Pelvik Ağrı: Pelvik Tabana Özgü Değerlendirme ve Manuel Yaklaşımlar

Öz

Muskuloskeletal nedenlere dayanan kronik pelvik ağrı (KPA) özellikle pelvik taban olmak üzere abdominal duvar, pelvik kuşak ve lumbal bölgede yumuşak doku disfonksiyonları ve tetik noktalar ile karakterizedir. Manuel bir uygulamaya veya kuvvetlendirme programına başlamadan önce intravajinal muayene ile pelvik taban kaslarının tonus, kuvvet ve enduransı değerlendirilir. KPA’da pelvik taban kasları genellikle aşırı aktif olup gergin bant ve tetik noktalar barındırır. Aşırı aktif ve hipoaktif pelvik tabanın tedavisi oldukça farklılık göstereceğinden tedavi programı muayene bulgularına göre şekillendirilmelidir. Fizyoterapi, bu alandaki uluslararası derneklerin yayınlamış olduğu rehberlerde ve bağımsız derlemelerde KPA için bir tedavi seçeneği olarak yer almaktadır. Manuel terapi uygulamaları bir görüş birliği oluşturacak kanıt düzeyine sahip olmamasına rağmen böylesine karmaşık bir kronik ağrı sendromunda tedavi için bir alternatif oluşturmakta ve ümit vadetmektedir. Literatürde pelvik tabanda iskemik kompresyon, miyofasyal gevşetme ve postizometrik relaksasyon tekniklerinin kombine kullanımı, abdominal duvar ve pelvik kuşakta tetik nokta deaktivasyonu ve thiele masajının etkileri gösterilmektedir. Manuel terapi uygulamaları sadece pelvik taban ile sınırlı kalmamalı, abdominal duvar, pelvik kuşak, alt ekstremiteler de tedavi programına dahil edilmelidir. Postür, dizilim bozuklukları ve solunum paternleri de göz önünde bulundurulmalıdır. Manuel terapi uygulamaları, uygun egzersizlerle kombine edilerek, endikasyon gösteren hastaların seçilmesi ile muskuloskeletal KPA tedavisinde kilit rol oynayabilir.

Anahtar Kelimeler

• İskemik kompresyon
• Kronik pelvik ağrı
• Manuel terapi
• Pelvik taban muayenesi
• Tetik nokta
• Thiele masajı

Kaynakça

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