By Shannon Pacella
While attending the 3rd World Congress on Abdominal and Pelvic Pain organized by the International Pelvic Pain Society, I had the privilege of listening to Rhonda K. Kotarinos, DPT, MS give a lecture on the topic of urologic chronic pelvic pain and manual physical therapy. Rhonda K. Kotarinos, DPT, MS is a Doctor of Physical Therapy practicing at Kotarinos Physical Therapy, where she treats women and men experiencing pelvic floor dysfunction. Her aim in this lecture was to discuss manual physical therapy treatments for urological chronic pelvic pain syndromes, including research, treatment guidelines, and defining/explaining the manual physical therapy techniques of trigger point release, connective tissue manipulation, and neural mobilization and stretching.
Left to right: Rhonda Kotarinos, Diane Lee, Ramona Horton, Stephanie Prendergast in the #WCAPP17 Musculoskeletal Panel
The American Urological Association’s guideline on the diagnosis and treatment of Interstitial Cystitis/Painful Bladder Syndrome can be found here, and includes:
“Appropriate manual physical therapy techniques (e.g., maneuvers that resolve pelvic, abdominal and/or hip muscular trigger points, lengthen muscle contractures, and release painful scars and other connective tissue restrictions), if appropriately-trained clinicians are available, should be offered to patients who present with pelvic floor tenderness. Pelvic floor strengthening exercises (e.g., Kegel exercises) should be avoided.”1
Many practitioners mainly focus on solely addressing trigger points, but Dr. Kotarinos made a point to explain that there are three important areas of manual physical therapy that need to be used in order to successfully treat these conditions:
- Trigger Point Release
- Connective Tissue Manipulation
- Neural Mobilization and Stretching
Trigger Point Release
What exactly is a trigger point, you might ask? A trigger point is defined as a hyperirritable spot in skeletal muscle associated with a hypersensitive palpable nodule in a taut band.2 A trigger point inhibits a muscle’s ability to lengthen and shorten appropriately. Digital/manual compression of a trigger point may result in referred pain or tenderness, as well as a local twitch response (transient contraction of muscle fibers in response to stimulation).2 Trigger points located along muscles surrounding the abdomen, pelvis, gluteals, and thighs may contribute to urinary dysfunction and chronic pelvic pain symptoms.
Connective Tissue Manipulation
Connective tissue manipulation (CTM) is a manual technique using skin rolling aimed at treating connective tissue changes in the referral zones of myofascial trigger points and somato-visceral/viscero-somatic reflexes.3 The connective tissue changes being treated are a result of reflex vasoconstriction in the referral zone.3 The goals of CTM are to improve circulation, decrease ischemia, restore tissue integrity, decrease adverse reactions in the viscera and neural tension in peripheral nerves. If you’re interested in more information on connective tissue, check out this previous PHRC blog post here.
Neural Mobilization and Stretching
A patient’s symptoms may arise from neural tissue, if the nervous system’s movement and elasticity is impaired. The pudendal nerve is the most commonly recognized nerve involved in pelvic pain, but that is not the only one. The posterior femoral cutaneous nerve (PFCN) is another nerve that is often impaired in patients with pelvic pain. The PFCN runs along the gluteal fold (the place where the buttocks meets the thigh) and under the ischial tuberosity. Due to the location of the PFCN, and the fact that it is more superficial than the pudendal nerve, it may get compromised first with prolonged pressure from sitting. Some people also notice that tight underwear (especially the band around the thigh) can be irritating to the PFCN. Neural mobilization and stretching is a manual physical therapy technique focused on improving neural movement by integrating neurodynamics and a variety of passive and active movements.
Pelvic Floor Lengthening Exercises
In many cases of chronic pelvic pain, the pelvic floor muscles are in a state of contracture creating what we call a short pelvic floor. Kegels or pelvic floor contractions are contraindicated for someone with a short pelvic floor. A contracture is a marked decrease in muscle length where ROM in the direction of elongation is limited.4 What is indicated to treat this dysfunction are pelvic floor lengthening exercises. Pelvic floor lengthening exercises are also known as pelvic floor drops and reverse kegels that allow the pelvic floor muscles to eccentrically lengthen from the muscle’s resting tone.
Dr. Kotarinos was part of the Randomized Multicenter Feasibility Trial of Myofascial Physical Therapy for the Treatment of Urological Chronic Pelvic Pain Syndromes, published in the Journal of Urology in 2012. This study compared two manual therapy methods (myofascial physical therapy versus global therapeutic massage) in patients with urological chronic pelvic pain syndromes.5 Two groups were formed, one received myofascial physical therapy, while the other received global therapeutic massage, for ten weekly treatments that lasted one hour each. The myofascial physical therapy group received connective tissue manipulation, trigger point release, and pelvic floor lengthening exercises; stretching was given as a home exercise program if appropriate. The global therapeutic massage group received full body Western massage.5 The patient global response assessment (GRA) was used to determine the patient’s response to the treatment.5 The GRA measures overall improvement with therapy. The assessment asks: “As compared to when you started the study (treatment), how would you rate your symptoms now?” The seven point scale is centered at zero (no change): markedly worse; moderately worse; slightly worse; no change; slightly improved; moderately improved; and markedly improved. Patients were considered positive responders to the treatment they received if they stated that their symptoms were moderately or markedly improved compared to before treatment.5 57% of the patients who received the myofascial physical therapy had moderately or markedly improved symptoms versus only 21% of patients who received the global therapeutic massage had a positive response to treatment.5
At PHRC, I believe we do our best to incorporate the manual physical therapy treatment techniques of trigger point release, connective tissue manipulation, neural mobilization and stretching, and pelvic floor lengthening exercises in order to appropriately address patients with urologic chronic pelvic pain syndromes. This lecture was enlightening and reinforced my understanding of the treatments best used for these conditions. Dr. Kotarinos has been so very influential for the field of pelvic floor physical therapy.
We thank Rhonda K. Kotarinos, DPT, MS for a fantastic lecture. To view the powerpoint in its entirety please start on page 192 here.
References:
- Diagnosis and Treatment Interstitial Cystitis/Bladder Pain Syndrome. Auanet.org. http://www.auanet.org/guidelines/interstitial-cystitis/bladder-pain-syndrome-(2011-amended-2014)#x2785. Published 2011; Amended 2014. Accessed November 12, 2017.
- Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual. Volume 2. Baltimore, MD: Williams & Wilkins; 1992.
- Dicke E, Schliack H, Wolff A. A manual of reflexive therapy of the connective tissue. S. S. Simon; 1978.
- Kendall FP, McCreary ED, Provance PG. Muscles: testing and function. 4th Edition. Baltimore, MD: Williams & Wilkins; 1993.
- FitzGerald MP, Anderson RU, Potts J, et al. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol. 2013;189: S75-S85.
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.