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.
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.
- 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.