By: Morgan Conner, DPT, PHRC Los Gatos
In October I had the pleasure of attending the International Pelvic Pain Society’s Scientific Meeting with a number of my colleagues here at PHRC. On the second day of the main conference, Catherine Allaire MDCM, FRCSC gave the James E. Carter keynote lecture titled Endometriosis: Towards Prevention of Chronic Pain. There were two primary themes to Dr. Allaire’s lecture. The first was a review of the current understanding of and evidenced-based integrated approach to endometriosis related chronic pelvic pain (CPP). The second half was a discussion on the importance of how early recognition of endometriosis can help prevent CPP and the various strategies that may be successful in doing so. If you are unfamiliar with endometriosis here are a few blogs about it here, here, here, or here.
In looking at the current understanding of endometriosis related CPP, Dr. Allaire started with an overview of endometriosis facts and figures. The most disappointing to me was the 8-10 YEAR delay between onset of symptoms and diagnosis. Additionally, endometriosis has a prevalence of one in ten and is often associated with decreased social and economic participation, comorbidities, and progression to chronic pain. Three common symptoms of endometriosis are dysmenorrhea, pelvic pain, and dyspareunia, with 90% of patients reporting dysmenorrhea. This is important because it is also the cardinal symptom.
Endometriosis-related pain can be nociceptive, inflammatory or neuropathic. With CCP it is often neuropathic in nature. At this point, it would be irresponsible to talk about chronic pain without also talking about central sensitization (when the central nervous system becomes oversensitized leading to normal stimuli being labeled as dangerous/painful). Dr. Allaire summarized a study by Grundstrom et al that investigated the relationship between pain thresholds, chronic pain and endometriosis.
She highlighted the following:
1) There were reduced pain thresholds in women with CPP and suspected endometriosis
2) Presence of endometriosis did not matter with regards to CPP and reduced pain threshold
3) Duration of pain was most predictive of low pain threshold
She also highlighted the reduction in grey matter volume in the regions of the brain that are important in anti-nociception (simply, the area of your brain that says, “I feel that sensation but it’s not bad enough to ring the pain alarm bell, so we’re cool here!”). To recap so far: there is an 8-10 year delay in diagnosis when patients are experiencing repeated monthly pain, and during this time, their pain thresholds are reducing and their brains are not properly regulating pain signals. Additionally, cross-sensitization of nerves that supply different structures such as bladder, bowel or musculoskeletal system can lead to problems in these systems on top of the endometriosis. Sounds likes a pile-o-fun right?!?
To conclude the first half of her lecture Dr. Allaire described how endometriosis is a diagnosis that is best managed when there are multiple different disciplines involved. Often this takes the form of a “multidisciplinary approach” where the patient sees one practictioner who then refers out to other disciplines and care is provided simultaneously but not integratively. A better approach is one that is “interdisciplinary” where different disciplines are working together, preferably in the same location and even sharing one central chart.
The center that Dr. Allaire works at is just that. She described their program for patients with central sensitization whose pain has not been or is not being managed well by their primary care team. It is a short intensive program where patients see physical therapists, counselors, nurse case management, and gynecologists and at the end leave with a clear diagnosis and treatment plan that can be managed by their regular care team. You can read more about the program on their website: www.womenspelvicpainendo.com.
In the second half of Dr. Allaire’s lecture, she spoke about how to prevent the development of chronic pain due to endometriosis. The adequate management of endometriosis is critical to preventing the negative impacts of chronic pain on all aspects of quality of one’s life. Unfortunately, this is not happening (remember that 8-10 year delay in diagnosis??). Some of the factors that lead to this delay include the taboos, misinformation and stigma around menstruation such as the normalization of women’s pain (“periods just hurt, get over it and go take some advil!”, no wrong answer, try again). There is also inadequate training of primary care providers to recognise that early signs of endometriosis, in fact 63% of endometriosis patients were told by their PCP that there was nothing wrong! Both of these problems can be improved with proper education. Encouragingly there are education programs for school aged children of all genders about endometriosis popping up in various places like Australia, New Zealand, and New York State. Other steps Dr. Allaire presented to help prevent endometriosis related CPP are to suppress painful menses early and effectively and recognise patients at risk for centralized pain and treat any comorbidities.
Endometriosis was discussed in multiple lectures at IPPS this year and I think that Dr. Allaire’s lecture provided a great overview of how we can put all this knowledge into providing better care for these patients to both treat and prevent endometriosis-related chronic pain. As a physical therapist, this lecture highlighted for me that often patients with endometriosis and chronic pain that I see have likely been dealing with this for years, if not decades. Their treatment journey probably hasn’t been smooth. As physical therapists we are educated about chronic pain and its mechanisms and we often have a lot more time with our patients than a physician which puts us in an almost perfect place to educate patients on the mechanisms behind chronic pain which can in itself help reduce pain.1 I often spend most of the time during sessions talking with my patients as I work. These conversations serve multiple purposes and cover a range of topics, from helping patients feel more relaxed and comfortable in an uncomfortable situation, to distraction from pain (sometimes unwinding years of pain is itself painful and talking about how cute/ridiculous/weird your cats are can help take your mind off of it!), to educating patients about why I am doing what I am doing or about what I think has lead them to be on my table that day. Chronic pain education is often part of these conversations although I think that adding in these pearls that relate to endometriosis specifically for our patients that struggle with it can help give them a better picture of how their bodies are working.
I would like to thank Dr. Catherine Allaire for a wonderful and informative lecture and to IPPS for an educational conference. If you are experiencing endometriosis related pelvic pain, we are here to help. You can all any of our offices and schedule an evaluation with any one of our pelvic floor physical therapists!
Reference:
Additional Resources:
PHRC’s YouTube Webinar, Pelvic Pain Explained: Endometriosis
PHRC’s Endometriosis Resource Blog
Pelvic Pain Explained by PHRC cofounders Steph and Liz
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
You correctly state ”
1) There were reduced pain thresholds in women with CPP and suspected endometriosis
2) Presence of endometriosis did not matter with regards to CPP and reduced pain threshold
3) Duration of pain was most predictive of low pain threshold”
Bu then later talk about the need to diagnose endometriosis early? Yet in point 2 say “Presence of endometriosis did not matter” – surely instead of focussing so ,much on diagnosing endo we should focus our limited resources on Treating pain/symptoms?
I think I understand what you are suggesting: that instead of focusing on diagnosing endometriosis, we should focus limited resources on treating pelvic pain symptoms. While I agree that treating pelvic pain/symptoms should be a priority, what I believe the speaker of this talk was trying to emphasize that was early diagnosis of endometriosis is critical for doing just that, treating and preventing pelvic pain as well as preventing any future overlapping/comorbid conditions that often develop with endometriosis and can lead to poor quality of life. Additionally, as endometriosis is the leading cause of dysmenorrhea, it is my opinion that to not investigate further is doing a disservice to those young people who are coming to their health care providers asking for help. As a pelvic floor physical therapists we can help with refractory pelvic floor dysfunction from endometriosis, however without concurrent medical management including an accurate medical diagnosis, these patients could be missing a valuable puzzle piece in managing their pelvic pain.