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2. therapy

Physical Therapist Management of Chronic
Prostatitis/Chronic Pelvic Pain Syndrome
Linda S. Van Alstyne, Kendra L. Harrington and Esther
M. Haskvitz
PHYS THER. Published online September 23, 2010
doi: 10.2522/ptj.20090418
The online version of this article, along with updated information and services, can be
found online at: http://ptjournal.apta.org/content/early/2010/09/23/ptj.20090418
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Case Report
Physical Therapist Management of
Chronic Prostatitis/Chronic Pelvic
Pain Syndrome
Linda S. Van Alstyne, Kendra L. Harrington, Esther M. Haskvitz
Background and Purpose. Chronic prostatitis/chronic pelvic pain syndrome
(CP/CPPS) negatively affects quality of life and sexual function in men of all ages.
Typical treatment with antibiotic and antimicrobial drugs often is not successful. The
purpose of this case report is to describe a multimodal physical therapy intervention
that included manual therapy techniques applied to the pelvic floor in 2 patients who
were unsuccessfully treated with the biomedical model of prescription drug
therapies.
Case Description. Two men, aged 45 years and 53 years and diagnosed with
chronic prostatitis, were referred for physical therapy following unsuccessful pharmacological treatment. The patients were treated with manual therapy techniques
applied to the pelvic floor and instructed in progressive muscle relaxation, flexibility
exercises, and aerobic exercises.
Outcomes. Changes in the patients’ National Institutes of Health Chronic Prostatitis Symptom Index revealed differences between preintervention and postintervention scores reflecting decreased pain and improved quality of life. One patient
improved from a score of 25 (total possible score⫽43) before treatment to a score of
0 after treatment, and the other patient improved from a score of 29 to a score of 21.
Discussion. Manual therapy techniques applied to the pelvic floor and performed
by a physical therapist specially trained in these techniques, along with progressive
muscle relaxation, flexibility exercises, and aerobic exercises, appeared to be beneficial to both patients in reducing pain and improving sexual function.
L.S. Van Alstyne, PT, DPT, OT, is
Physical Therapist, Physical Therapy Associates of Schenectady,
1182 Troy Schenectady Rd, Suite
LL02, Latham, NY 12110 (USA).
Address all correspondence to Dr
Van Alstyne at: vancampt@
earthlink.net.
K.L. Harrington, PT, DPT, MS,
WCS, BCB-PMD, is Associate Director, Department of Residency/
Fellowship & Specialist Certification, American Physical Therapy
Association, Alexandria, Virginia.
E.M. Haskvitz, PT, PhD, ATC, is Interim Dean, School of Health Sciences, and Professor, Physical
Therapy, The Sage Colleges, Troy,
New York.
[Van Alstyne LS, Harrington KL,
Haskvitz EM. Physical therapist
management of chronic prostatitis/chronic pelvic pain syndrome.
Phys Ther. 2010;90:xxx–xxx.]
© 2010 American Physical Therapy
Association
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Physical Therapist Management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome
P
rostatitis is estimated to affect
2% to 10% of men, and 90% to
95% of those with chronic prostatitis also have chronic pelvic pain
syndrome (CP/CPPS).1 Prostatitis is
the third most common diagnosis of
men under 50 years of age presented
to urologists annually.2 According to
the current medical consensus on establishing an etiology of CP/CPPS,
the condition arises from multiple
factors, including neuronal, inflammatory, hormonal, and psychological factors.1,3,4 Chronic prostatitis/
chronic pelvic pain syndrome is
believed to be initiated by an inflammatory trauma that involves the immune system and subsequently affects the complex neuronal circuitry,
leading to psychological distress as
pain coping strategies fail.1,4 Men experiencing the pain of CP/CPPS and
lower urinary tract symptoms (LUTS)
have a high incidence of depression
and helplessness.5
Primary symptoms include pelvic,
genital, or perineal pain with associated bladder dysfunction, including
LUTS, and sexual dysfunction.6,7 Additional symptoms may include dysuria, increased urinary frequency, incomplete bladder emptying, pain
following ejaculation, and scrotal,
penile, coccygeal, rectal, and lower
abdominal pain.1,7 Pelvic pain can result in sexual dysfunction, which
negatively affects couples’ relationships and sexual satisfaction.8 Men
with complaints of sexual dysfunction and voiding problems account
for 2 million physician visits a year.9
Diagnosing CP/CPPS is difficult, as
there are no gold standard tests to
confirm the condition.10 The physician must rule out infections, abdominal wall defects, malignancies, and
neurological, urologic, gastrointestinal, musculoskeletal, and psychiatric
diseases and conditions. The current
consensus on basic diagnostic criteria includes a thorough patient history, a digital rectal examination
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Physical Therapy
(DRE), a urinalysis, and the administration of the National Institutes of
Health Chronic Prostatitis Symptom
Index (NIH-CPSI), a validated symptom questionnaire.10 In addition, the
patient must have symptoms lasting
longer than 3 months.6,11 Secondary
diagnostic criteria can include laboratory and imaging studies, although
they are considered optional for
CP/CPPS.10
The most common treatment of CP/
CPPS is antibiotics and antimicrobial
therapies,12 despite studies demonstrating that there is no evidence of
bacterial infection or inflammation.13,14 Studies have not shown
these treatments to be effective in
decreasing patients’ symptoms over
time.15–18 These studies,15–18 however, were either uncontrolled or
lacked power, used off-label dosages,
or failed to show meaningful change
of quality of life (QOL) or lasting relief of the pain and LUTS during the
extended follow-up period.19 In addition, pain, QOL scores, and NIHCPSI scores have been found to increase significantly in patients
treated repetitively with these
agents.12
Due to the similarity in symptoms
with another painful bladder syndrome, interstitial cystitis, muscle
tension and muscle tenderness are
possible etiologies for the pain related to CP/CPPS. A retrospective
study by Zermann and colleagues20
showed that 88.3% of 103 participants experienced a pathological
tenderness of the striated pelvicfloor muscles on physical examination. These men were unable to relax the pelvic-floor muscles with
repeated trials.20 The failure of antimicrobial interventions in treating
CP/CPPS, coupled with successful
patient outcomes achieved with neuromodulation for pain reduction and
improved voiding, led Zermann and
colleagues to believe there is a neurological basis for the pain that leads
to urinary dysfunction in patients
with CP/CPPS. Tension in striated
pelvic-floor muscle could set off and
perpetuate this onslaught of neurological events, including visceral
pain and neurogenically maintained
myofascial pain syndrome.20
Further studies have indicated a relationship between pelvic-floor muscle tension and symptoms of CP/
CPPS.13,21 Hetrick and colleagues21
conducted a partially blinded casecontrol study and examined musculoskeletal function and pelvic-floor
myofascial tenderness of patients diagnosed with CP/CPPS compared
with controls who had no evidence
of CP/CPPS nor a history of urinary
or sexual dysfunction. The authors
found a difference in pelvic-floor
muscle tension both internally and
externally in men diagnosed with
CP/CPPS compared with the control
group. The results indicated that
men with CP/CPPS were much more
likely to have palpable tenderness in
the muscles of the external and internal pelvis. The study was limited
by its observational design, lack of a
validated test to measure pelvic-floor
muscle function, and lack of a second examiner to establish interrater
reliability.21
According to the results of the study
by Hetrick and colleagues21 and similar findings of Berger et al,13 Potts,22
and Weiss,23 CP/CPPS can be categorized as a pelvic-floor muscle tension
syndrome. These findings have allowed for the expansion of treatment options for CP/CPPS from the
primarily pharmacologic treatment
to the inclusion of neuromodulation
of central nervous system excitability, as well as manual therapy compression techniques applied to the
pelvic floor.
Simons and colleagues24,25 defined a
tender point as a taut band of muscle
with a palpable tender nodule or a
local tender area. If present, when
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Physical Therapist Management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome
pressure or compression is applied
at the tender nodule or tender area,
the patient will experience a reproduction of the familiar pain pattern.
Other characteristics of a tender
point include referred pain within 2
cm beyond the tender area, a local
twitch response or jump sign, weakness without atrophy, restricted
range of motion, sensitivity when
the muscle is stretched, tightness in
the muscle, and an automatic response to a remote area such as vasomotor constriction and hypersecretion.26 Several studies have
attempted to validate Simons and
colleagues’ work. Many possible etiologies for tender points located in
taut bands of muscle have been hypothesized, yet none have been validated to date.27–29
Similar to the difficulties in diagnosing CP/CPPS, no gold standard exists
for diagnosing palpable tender
points within a muscle. A recent descriptive study of 9 individuals by
Sikdar et al30 successfully used ultrasound to visualize and characterize
palpable tender points located
within a taut band in the upper trapezius muscle. Both active and latent
palpable tender points demonstrated
scores reflecting higher tissue imaging than in normal tissue.30 In reviewing the literature on criteria to
diagnose tender points found by palpation, Tough and colleagues31
found that more than half of the studies reviewed included only taut
band, local tender spot, and reproduction of familiar pain as their diagnostic criteria, without consideration of referred pain, local twitch
response, and painful or limited
movement. Gerwin et al32 established interrater reliability among investigators in locating and palpating
tender points in several muscles,
with good agreement on 5 of the 6
diagnostic measures. The local
twitch response was the least reliable characteristic to identify. Accurate location of tender points has
December 2010
been made by the use of an algometer, a tool that measures pain caused
by pressure, with good reliability,
but there is no documentation of the
use of algometry for internal pelvic
tender point examination.33 Thus,
the diagnosis of tender points is established via a thorough patient history coupled with a manual examination performed by an experienced
clinician.32 Evidence of regional pain
with abrupt muscle overload, repetitive muscle activity, sustained muscle contraction, and constant tension
or holding patterns are keys to making the diagnosis of myofascial pain
syndrome with tender points.26
Effective treatment techniques for
reducing tender points in the pelvicfloor musculature are lacking in the
literature. However, many authors
have reported successful treatment
of myofascial pain and tender points
in other areas of the body.23,34 –36 In a
systematic review conducted by de
las Peñas et al,37 little evidence was
found to confirm or refute the effectiveness of manual therapy for treatment of palpable tender points
within a muscle. In 2 of the studies,
there was an increase in pressure
pain threshold at the site of the taut
band, indicating a positive effect of
manual physical therapy. In a study
comparing manual therapy compression techniques for treatment of palpable tender points in the muscle
with transfriction massage, de las Peñas et al37 found both techniques
were effective in pain reduction and
increasing pain pressure threshold in
the upper trapezius muscle. Patients
who had tender points located in the
muscles of the back or neck region
and who were instructed in a home
program of maintained pressure into
the taut band and tender spot followed by sustained muscle stretching were found to achieve decreased
pain and increased range of motion
after only 5 days of home
treatment.36
Manual therapy compression techniques applied to the pelvic floor
also have been found to be an effective treatment to reduce painful
symptoms of patients diagnosed
with interstitial cystitis and urgencyfrequency syndrome.23 In addition,
83% of 146 patients studied reported
moderate improvement in symptoms of postejaculatory pain, decreased libido, and forms of erectile
dysfunction following physical therapist– delivered manual transrectal
ischemic compression techniques
and paradoxical relaxation.35 Paradoxical relaxation is a term coined
by Wise to describe specific relaxation techniques used to encourage
patients to accept and release their
pelvic-floor muscle tension.34 However, there is uncertainty about the
duration of the treatment protocol38
and whether manual therapy techniques applied to the pelvic floor
alone can provide successful treatment of CP/CPPS.34
Although CP/CPPS is a common diagnosis among men seeking treatment from a urologist, very few studies have reported success with
antimicrobial
therapies.15,17,18,39
Studies have indicated a relationship
between pelvic-floor muscle tension
and tender points as a possible etiology for the symptoms associated
with CP/CPPS.20 –23 Manual therapy
compression techniques applied to
the tender points in the pelvic floor
coupled with paradoxical relaxation
has been described as an effective
treatment for CP/CPPS.34 However,
the clinical utility of ischemic compression applied to the pelvic-floor
tender points as the primary intervention for CP/CPPS has not been
reported. This case report describes
a multimodal physical therapy intervention that included manual therapy techniques applied to the pelvic
floor in 2 patients with CP/CPPS
who were unsuccessfully treated
with the traditional biomedical
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Physical Therapist Management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome
Table 1.
Patient Characteristics
Characteristic
Patient 1
Age (y)
42
Duration of symptoms
⬎15 mo
Patient 2
53
a
⬎3 y
b
c
Flomax,d Uroxatral,e Cipro, Levaquin, saw palmetto
Previous treatment
Cipro, Levaquin, cyclobenzaprine, diazepam, Pyridium,
saw palmetto
Comorbid conditions
Irritable bowel syndrome, asthma, urethral stones
Irritable bowel syndrome, duodenal ulcer, chronic
low back pain
Diagnostic testing
Negative
Negative
a
Merck & Co Inc, One Merck Dr, PO Box 100, Whitehouse Station, NJ 08889.
Ortho-McNeil Pharmaceutical Inc, 1125 Trenton-Harbourton Rd, PO Box 200, Titusville, NJ 08560.
Pfizer Inc, 235 East 42nd St, New York, NY 10017.
d
Astellas Pharma Technologies Inc, Norman, OK 73072.
e
Sanofi-Aventis US, LLC, 55 Corporate Dr, Bridgewater, NJ 08807.
b
c
model of prescribed pharmacological treatment.
Case Description
Patient History
Two male patients with the diagnosis of prostadynia/prostatitis were referred by their urologist to a physical
therapist who was specially trained
in pelvic-floor physical therapy for
examination and treatment. A summary of their characteristics is presented in Table 1.
Patient 1 was referred for physical
therapy with a chief complaint of
pain in the fleshy skin between the
scrotum and anus, which he described as sharp and jabbing. Symptoms were aggravated by ejaculation
and sitting. He also complained of
increased urinary frequency and dysuria following urination. Although
he experienced hesitation at initiation of urination, he described his
urine flow as strong and steady. The
patient had recently returned to
school and reported increased sitting
during class, driving to school, and
while studying, which aggravated his
symptoms. He described his physical
activity level as sedentary. He had
one episode of hematuria; however,
his urinalysis was negative for infection. A sonogram of the scrotum also
was negative. Prescribed medications for prostadynia/prostatitis in4
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cluded long-term cycles of antibiotics, although there was no evidence
of bacterial infection in urine cultures or prostate secretions. Treatment also included 2 trials of muscle
relaxants, an analgesic, and an herbal
supplement. He experienced no relief with any of these oral medications. The patient’s goals were to resume activities without pain,
including urinating, intercourse, and
sitting.
Patient 2 was referred for physical
therapy with chief complaints related to the inability to sit for longer
than 5 to 10 minutes, postejaculation
pain in the tip of the penis, and dysuria. He described a sensation of bilateral gluteal muscle tightness at the
base of his buttocks. He had a history
of 3 urinary tract infections 3 years
prior, but no recurrence. In addition
to those symptoms, he described increased urinary frequency and a
burning sensation in his urethra that
caused a hesitation to initiate urination. Two years prior, sonograms of
the scrotum, kidney, and bladder revealed normal structures but a large
post-void residual volume. Although
he sat for most of his day at work, he
was an avid runner. He initially
thought that running was the cause
of his pain, but there was no increase
in pain during or after running 30
minutes per day. He was treated
with 2 ␣-blockers, which resolved
his post-void residual volume. Similar
to patient 1, this patient had repeated, long-duration series of antibiotics, although laboratory reports
did not indicate bacterial infection of
prostate secretions or urine. The patient also took an herbal supplement,
with no effect on symptom relief.
Lastly, he used omeprazole for his
duodenal ulcers. The patient’s goals
were to resume pain-free intercourse, to resolve urinary symptoms
of frequency and burning, and to increase sitting tolerance.
Clinical Impression
The history both patients presented
met the clinical description of CPPS.
Their primary symptoms included
genital and perineal pain with associated bladder dysfunction, including dysuria, increased urinary frequency, and hesitancy at the
initiation of urination. Both patients
described some degree of sexual dysfunction.40 The duration of their
symptoms was greater than 3
months. Their expressed musculoskeletal pain about the pelvis and
hips with poor sitting tolerance was
consistent with what Hetrick and
colleagues reported.21
Examination
After obtaining each patient’s history, several symptom outcome tools
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Physical Therapist Management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome
Table 2.
Numeric Pain Rating Scale40 Resultsa
Patient 1
a
Patient 2
Visit
Preintervention
Postintervention
Preintervention
Postintervention
1
9
5
8
5
2
7
4
5
4
3
7
4
N/A
N/A
4
5
3
N/A
N/A
5
5
2
N/A
N/A
6
7
5
N/A
N/A
7
7
3
N/A
N/A
8
5
2
N/A
N/A
9
3
1
N/A
N/A
10
3
0
N/A
N/A
11
0
0
N/A
N/A
Scores range from 0 to 10, with higher numbers representing greater pain. N/A⫽not applicable.
were used to evaluate their initial
symptoms and monitor their response to the interventions throughout their course of treatment. First,
both patients verbally rated their
pain using the numeric pain rating
scale (NPRS), which has been found
to yield reliable scores.40 These
scores are shown in Table 2. In addition to this symptom scale, each
patient completed the NIH-CPSI,
which was used as a pretreatment
symptom quantifier and posttreatment outcome tool.41 The NIH-CPSI
captures scores in 3 domains (ie,
QOL, pain, and urinary symptoms)
and has strong construct, face, and
criterion validity.41,42 Its internal
consistency (␣⫽.86 –.91) and retest
reliability (r⫽.83–.93) are high.41
Scoring is achieved by summing the
responses in each of the scaled items
in the 3 categories of pain, urinary
function, and QOL. A higher score
signifies worse outcomes in all 3 areas. In a study by Propert et al,42 the
NIH-CPSI scores were found to be
responsive to improvements over
time, and a 6-point decline in the
NIH-CPSI total score was determined
to be the optimal threshold to predict treatment response. The modified Pelvic Pain Symptom Survey
(PPSS) was used as an outcome tool
by Anderson and colleagues34 to
evaluate the sexual dysfunction of
each patient prior to and following
the physical therapy intervention.
The modified PPSS has not been validated. A summary of all outcome
scores is presented in Table 3.
An observational posture examination was performed to evaluate
asymmetry or postures that may
have increased pelvic tension or abdominal pressure. Functional mobility into the squatting position was
examined to evaluate any strain on
the pelvic floor. Antolak and colleagues43 found that sudden pain associated with squatting is one of the
5 symptom groups associated with
CPPS. The Thomas test was used to
rule out hip flexor contracture.44 Intraclass correlation coefficients
Table 3.
Pretherapy and Posttherapy Symptom and Quality of Life Scores
Patient 1
Measure
Patient 2
Pretherapy
Posttherapy
Pretherapy
Posttherapy
14
0
16
12
1
0
4
2
NIH-CPSI41,a
Pain or discomfort score (21)
Urination symptoms (10)
b
Impact of symptoms/QOL (12)
10
0
9
7
Total score (43)
25
0
29
21
Percentage of improvement42
PPSS34,c
Clinically significant difference of 25 points
3
Percentage of improvement
NPRS40,d (0–10 scale)
Clinically significant difference of 8 points
0
3
0
8
100
9
3
0
4
a
NIH-CPSI⫽National Institutes of Health Chronic Prostatitis Symptom Index. A change of 6 points on the NIH-CPSI is significant for patients to experience
an improvement of symptoms42; higher scores indicate more severe symptoms or greater impact of symptoms. Numbers in parentheses indicate total
possible score for each domain.
b
QOL⫽quality of life.
c
PPSS⫽Pelvic Pain Symptom Index.
d
NPRS⫽numeric pain rating scale.
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Physical Therapist Management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome
Table 4.
Examination Resultsa
Test
a
Patient 1
FABER test: hip mobility
(⫹) Right side
(⫹) Right and left
FABER test: pain provocation
Sharp pelvic and testicular pain reproduction
Minimal symptom production
Thomas test
Refused
Right⫽35°, left⫽⫺20°
Straight leg raise
55° bilaterally; no symptom reproduction
60° bilaterally; no symptom reproduction
Functional squat
Refused
Incomplete due to scrotal pain
Abdominal strength, upper/lower
3/5, 2/5
3/5, 3/5
Pelvic-floor muscle strength
0/5
1/5
Posture: spine
Mild thoracic kyphosis, flat lumbar spine
Mild thoracic kyphosis, flat lumbar spine
Posture: hips
Externally rotated right hip, standing
Midline of hips slightly anterior to center of gravity
Posture: shoulders
Internally rotated, scapular protraction
Internally rotated; scapular protraction
(⫹)⫽positive results, indicating limited movement into flexion, abduction, or external rotation.
(ICCs) for intrarater reliability of the
Thomas test have been reported in
the range of .43 to .59.44
The obturator internus muscle, a lateral rotator of the hip, lies within the
pelvic floor and is covered by one
half to two thirds of the iliococcygeus portion of the levator ani muscle.45 Because of the close proximity
of the hip rotator muscles to the
pelvic-floor muscles, restriction in
muscle length of this hip external
rotator may contribute to pelvicfloor tension or muscle spasm.45
With each patient in the supine position, the FABER (Patrick) test was
performed to test hip mobility and
sacroiliac joint pain.46 This test for
hip range of motion has been shown
to have good test-retest reliability
(ICC⫽.90).47 When used as a singlemotion palpation and pain provocation test for sacroiliac pain, the
FABER test was shown to have intrarater reliability ranging from
r⫽.31 to .91 and interrater reliability
ranging from r⫽.44 to .70.46 Martin
and Sekiya48 reported an acceptable
level of interrater reliability (r⫽.63)
for the FABER test when used to assess hip pain of musculoskeletal
origin.
Upper and lower abdominal strength
(force-generating capacity) was as6
Patient 2
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Physical Therapy
sessed.49 Theoretically, length and
strength imbalances around the pelvis, hips, and abdomen might increase tension on the pelvic-floor
muscles and contribute to pelvic
pain.25 The examination findings
for special tests, strength, and posture for both patients are shown in
Table 4.
A manual examination of the abdomen, groin, proximal thigh, and posterior buttock and a manual DRE to
assess rectal soft tissue were performed to locate tender points, taut
bands within the muscles, and referred or local symptomatic pain. Initially, the manual examination of the
abdomen, groin, proximal thigh, and
posterior buttock was conducted
with each patient positioned supine,
with a pillow under the knees, while
the abdomen was palpated in a
circular, clockwise direction. A
4-finger-width fingertip palpation
and a flat finger palpation were performed. The little finger was positioned at the umbilicus and the index finger toward the thorax and
inferior ribs. More than one pass was
made to scan the entire abdomen.
Particular attention was paid to this
region, as palpable tender points in
the lower lateral abdominal wall refer pain to the ipsilateral testicle.24
With the patient remaining in the
supine position, a manual assessment of the groin and anterior thigh
was performed using the same
4-finger-width fingertip and flat finger palpation starting at the medial
thigh and progressing to the lateral
thigh just inferior to the inguinal
crease. The patient then assumed a
prone position, with a pillow under
his abdomen to support the lumbar
spine. A clockwise palpation was
performed in the same manner over
the soft tissue and muscular attachments of the right and left buttocks,
hips, gluteal folds, and proximal
thigh. Both patients demonstrated
numerous palpable tender points
throughout the lower abdomen,
groin, proximal thigh, gluteal fold,
and posterior buttock muscles
(Figure).
A manual DRE of the internal pelvicfloor muscles was conducted in the
left side-lying, relaxed fetal position,
in a clockwise fashion, with the symphysis pubis at 12 o’clock and the
coccyx at 6 o’clock.45,50 These 2
bony landmarks are helpful in locating the muscles of the pelvic floor.
The puborectalis muscle lies between 3 and 9 o’clock anterior to the
iliococcygeus muscle. The obturator
internus muscle is at 2 and 10
o’clock at the lateral most reaches of
the fingertip. The examining finger
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Physical Therapist Management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome
Figure.
Palpable tender point locations. (Top) Patient 1: (a) lower right abdominal wall, (b) right gluteus maximus muscle, (c) bilateral
piriformis muscles, (d) right adductor muscles group, (e) right obturator internus muscle, (f) right pubococcygeus muscle, (g) right
bulbospongiosus muscle, (h) perineal body. (Bottom) Patient 2: (a) suprapubic upper left and (b) lower right lateral abdominal wall,
(c) right gluteus medius muscle, (d) right gluteus maximus muscle, (e) right iliacus muscle, (f) bilateral obturator internus muscle,
(g) bilateral pubococcygeus muscle.
moved along the pelvic clock, palpating for nodules, taut bands, and
muscle spasms that reproduced the
patient’s painful symptoms. Palpation of the pelvic-floor muscles in
patient 1 revealed dense flat sheets
with palpably taut bands and numerous tender points located within the
muscles. For patient 2, the pelvicfloor muscles were taut, which made
insertion of the examining finger difficult. During palpation of the pelvicfloor muscles, numerous tender
points were identified. Results of the
external and internal manual pelvicfloor examinations locating tender
December 2010
points for both patients are illustrated in the Figure.
Digital rectal pelvic-floor muscle
strength testing was performed with
the patient in the supine hooklying
position using the grading scale outlined by Chirarelli.45 This scale ranks
pelvic-floor muscle strength from 0
(no contraction) to 5 (a strong
squeeze with a good, repeatable lift
of the pelvic floor). Patient 1 was
unable to execute a pelvic-floor muscle contraction. In addition, he was
not able to isolate the pelvic-floor
muscles and used accessory muscle
recruitment of the hip adductors
when attempting to do so. Patient 2
had difficulty isolating the pelvicfloor muscles and was only slightly
successful when coached (Tab. 4).
Clinical Impression
Both patients’ total scores on the
NIH-CPSI were greater than 50% of
the total possible score, meeting the
diagnostic criteria of CP/CPPS. Manual assessment confirmed numerous
tender points externally and internally that corresponded with the
complaints of both men. Tender
points are activated in these pelvic-
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Physical Therapist Management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome
Table 5.
techniques were performed as outlined by Travell and colleagues.24,25
Therapeutic Exercises
Exercise
Patient 1
Patient 2
Supine hamstring muscle stretch
(⫹) bilateral
(⫹) bilateral
Supine bent knee fall out
(⫹) right
(⫹) bilateral
Supine hip flexor stretch
(⫹) bilateral
(⫹) bilateral
Piriformis muscle stretch
(⫹) right
(⫹) bilateral
Supine bent-knee position, isometric spinal extension and
shoulder retraction
(⫹)
(⫹)
Bilateral leg thrust on 25-cm therapy ball (lower abdominal
strengthening)
(⫹)
(⫹)
Alternate heel slide, lower abdominal strengthening
(⫹)
(⫹)
floor muscles when sitting in a
slumped posture for lengthy periods.25 Both patients displayed
slumped standing and sitting postures. The limited muscle length at
the hips and decreased abdominal
strength most likely contributed to
the postural faults, the increased tension on the pelvic-floor muscles, and
the
development
of
tender
points.21,25 The palpable tender
points in the lateral abdominal wall
can refer pain into the ipsilateral
groin and testicle.24 Studies have
confirmed the presence of tender
points identified by palpation in the
pelvic-floor muscles of men with
CP/CPPS.21,34,35
Evaluation and Diagnosis
The examination results for these 2
patients demonstrated findings consistent with the diagnostic classification Musculoskeletal Pattern 4C (disorders of muscle, ligament, and
fascia, including pelvic-floor muscle
dysfunction, muscle spasm/tension;
hypertension of the levator ani muscle).51 The treatment goals for each
patient were the same and included
elimination of pain, resumption of
pain-free intercourse, and increased
sitting tolerance. An additional goal
for patient 2 was diminished urinary
frequency.
Intervention
The intervention included 2 physical
therapy visits per week, consisting of
8
f
Physical Therapy
instruction in hip range of motion
exercises, postural correction education, postural strengthening exercises, and verbal instruction in totalbody paradoxical relaxation with a
focus on tension reduction in the
pelvic-floor muscles. The therapeutic exercise programs are outlined in
Table 5. Paradoxical relaxation, as
defined by Wise,34 focuses on releasing tension in the pelvic muscles
through mental focus on the presence of the tension, regulated
breathing to control anxiety, and
progressive muscle relaxation. Both
patients were encouraged to perform aerobic exercises (ie, either
fast-paced walking or running), daily
if possible. Aerobic exercises have
been shown to improve NIH-CPSI
scores greater than 6 points in men
who performed 40 minutes of fastpaced walking daily compared with
those who performed exercises
only.52 Treatment included 15 minutes of moist heat applied to the
lower abdominal region with the patient in the supine position and with
the knees supported on a 20-cm
wedge to encourage total-body relaxation. Ischemic compression was
first performed on the lower abdomen and thigh corresponding with
the tender points found on examination. The patient then was treated in
the prone position, with one pillow
under the abdomen to support the
lumbar spine. Ischemic compression
Transrectal tender point release
techniques were performed as described by Weiss,23 Travell et al,25
and Anderson et al.35 Each patient
was treated in the side-lying, relaxed
fetal position, with a pillow between
the knees. Manual techniques included strumming, examining finger
palpating perpendicular to the muscle fibers, and a single-digit stripping
or stroking massage, with the examining finger palpating along the
length of the muscle fibers of the
taut band, assessing tissue resistance
and presence of tender points. Maintained pressure was then applied (at
least 60 –90 seconds or more) up to
the patient’s pain pressure threshold
in the tender points until the pain
subsided. Movement was slow and
deliberate in order to identify each
tender point at various points within
the pelvic clock and was provided at
various depths, including the external anal sphincter, pubococcygeus,
and puborectalis portions of the levator ani muscle. The patient was
asked to perform isometric external
rotation in order to contract the obturator internus muscle while pressure was maintained internally on
the obturator internus tender points
with the transrectal finger.23,25
A post-isometric tender point release
is achieved when the pain subsides
and the muscle softens, allowing the
examiner’s finger to sink into the
softened muscle. Once the tender
points were released, an anterior inferior stretch was performed along
the muscle just lateral to midline of
the prostate, with the examiner’s finger flexed toward the symphysis pubis. Each patient was instructed in
pelvic-floor muscle exercises that
consisted of gentle tightening and relaxing of the levator ani muscle
group. The patient was cautioned
not to provide too much force during the contraction in order to avoid
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Physical Therapist Management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome
accessory muscle use or the development of a muscle spasm. Manual digital feedback was provided during
the training period. Each patient was
coached to perform a 10-second submaximal squeeze and a 10-second relax, for a total of 20 repetitions, in
order to inhibit the chronic holding
patterns.25,53
Patient 1 was seen for tender point
release, pelvic muscle exercises, and
instruction in muscle relaxation, aerobic exercise, stretching exercises,
and postural strengthening exercises
(Tab. 5) for a total of 11 visits. Patient
2 was seen on 7 occasions and received tender point release on 2 of
those visits. He chose to have his
wife, a massage therapist, learn the
technique and perform the manual
therapy at home. She was provided
with copies of the articles describing
the treatment techniques.23,34 In addition to the instruction provided to
patient 2’s wife, treatment included
moist heat and manual release of the
external abdominal and buttock tender points, as described for patient 1.
Patient 2 also was instructed in therapeutic exercises to increase right
hip range of motion using the supine
Thomas test position and in posture
correction exercises to restore lumbar lordosis in sitting and standing
positions (Tab. 5). He also received
instruction in aerobic exercise, including a walking program of 30
minutes 5 days per week, and muscle relaxation.
Outcome
Numeric pain rating scale scores
were obtained for each patient before and after each treatment
(Tab. 2). At the final treatment, each
patient was asked to complete a second NIH-CPSI and PPSS (Tab. 3).
Both patients demonstrated greater
than a 6-point reduction in NIH-CPSI
scores, which revealed a positive response to treatment.42 The patients
had changes of 8 and 25 points, the
changes are both greater than 6 (the
December 2010
minimal clinically important difference value). Patient 1 was receptive
to transrectal manual therapy and
demonstrated continued symptom
reduction at each visit (Tab. 2). At
the time of discharge, after he received a total of 11 treatments, he
reported a 100% reduction of all
symptoms and demonstrated an increase in pelvic-floor muscle
strength from 0/5 to 3/5. At the time
of discharge from physical therapy,
patient 2 had an 8-point decrease in
NIH-CPSI scores (Tab. 3). The PPSS
score for patient 1 was 0 at time of
discharge, and he had returned to
pain-free intercourse. There was no
change in the PPSS score of patient 2
at time of discharge. Both patients
received a 1-year posttreatment
follow-up telephone call. Each patient reported pain-free activity, including the ability to sit for sustained
periods and a return to intercourse
with no postejaculation pain. Patient
2 reported resolution of urinary
symptoms. The NPRS scores were 0
for both patients.
Discussion
This case report describes the physical therapist management of 2 patients with CP/CPPS with multimodal physical therapy intervention
that included manual therapy techniques applied to the pelvic floor as
the primary intervention. The pelvicfloor manual therapy was provided
transrectally, as described by
Weiss.23 The NIH-CPSI urinary symptom scores were low for both patients. The urinary symptom scores
are least discriminative between
men with CP/CPPS and controls who
are healthy.41,42 Prior to the intervention, both men scored high on the
QOL and pain categories of the NIHCPSI, indicating more-severe symptoms. Higher scores in these 2 sections have been found to be the most
predictable to confirm a diagnosis of
CP/CPPS.41 Tripp et al5 reported in
their study of predictors of QOL that
higher pain scores had a more nega-
tive impact on QOL in patients with
CP/CPPS than higher urinary symptom scores. Schaeffer and colleagues12 found a relationship between NIH-CPSI scores higher than
22 and the presence of internal pelvic tenderness. Both men had scores
higher than 22, and both men had
high QOL scores compared with the
other 2 NIH-CPSI domains. Turner et
al54 reported that men with recurrent symptoms and NIH-CPSI scores
greater than 15 were more likely to
have lingering symptoms at 12
months compared with men with
lower NIH-CPSI scores or those experiencing their initial onset of
symptoms. Both patients described
in this case report had high scores,
and both had recurrent and lingering
symptoms over 1 year. Neither patient received any benefit from antibiotic or ␣-blocker therapy. Both patients had negative laboratory tests
for infection or inflammation, and
their failure to respond to prescribed
medications matched outcomes of
previous randomized, double-blind
studies.15,17–19 Based on their high
NIH-CPSI scores, LUTS, and the presence of multiple tender points, these
2 patients were optimal candidates
for manual pelvic-floor physical
therapy for CP/CPPS symptom
reduction.
The studies by Berger et al13 and
Hetrick et al21 confirm the presence
of pelvic tender points in men diagnosed with CP/CPPS. Travell and Simons25 identified the location of
pelvic-floor tender points. Both patients had internal and external pelvic tender points that matched the
descriptions in previous studies.13,21,23,25 Tender points in muscles that attach to the bony pelvis
and in close proximity to pelvic organs are responsible for pain symptoms in that region.24,25 Therefore, in
the absence of a medical diagnosis
for the pelvic pain symptoms that
both men were experiencing, treating the tender points to decrease
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Physical Therapist Management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome
painful symptoms may have been a
more appropriate treatment than antibiotics and ␣-blocker therapy.
There are other methods for tender
point release, including needling
techniques and coolant sprays.55,56
Neither of these treatment methods
is practical for transrectal tender
points. Weiss23 demonstrated the
positive effects in symptom reduction using the techniques of pelvicfloor tender point release, as described by Travell and Simons.25
These techniques include stripping
or stroking massage and maintained
pressure, strumming, post-isometric
release, and stretch. Anderson and
colleagues34,35 expanded on this approach and added an extensive training in paradoxical relaxation to the
tender point treatment. Because
many authors reported on the similarities of interstitial cystitis and CP/
CPPS and both patients demonstrated these symptoms, the
treatment protocol described by
Weiss23 was thought to be an appropriate treatment approach for both
patients.57–59 The work of Anderson
and colleagues34 stressed a combined treatment of tender point
release and intense training in paradoxical relaxation. The primary intervention for the patients in this
case report was tender point release
with a secondary focus on paradoxical relaxation training, aerobic exercises such as walking, and posture
and flexibility exercises to be carried
out at home.
For both patients described in this
report, the diagnosis of CP/CPPS was
addressed as tension myalgia with
the presence of tender points, and
the described manual pelvic-floor
physical therapy treatment methods
used with these 2 patients was
shown to be effective in reducing
symptomatic pain. Both patients
demonstrated pelvic and postural
muscle weakness and limited range
of motion at the hips, which can
10
f
Physical Therapy
contribute to pelvic pain. Instruction
in exercise to increase strength and
range of motion and to improve posture was included in the treatment
plan. The patients were encouraged
to participate in self-help treatment
by performing aerobic exercise,
stretching exercises, and muscle relaxation techniques to decrease
pelvic-floor tension and improve
their ability to control symptoms following successful tender point release.52 Studies have shown that relaxation and aerobic exercise have a
positive impact on reducing tension
in the pelvic floor.52,60
Based on the outcomes of the study
by Weiss,23 treatment with tender
point release should be successful in
12 physical therapy visits, or up to
12 weeks, with 1 to 2 visits per
week. Both patients had limited
physical therapy visits approved by
insurers, so the protocol described
by Weiss23 seemed applicable. Patient 1 completed 11 physical therapy treatments, but patient 2 was
more reluctant to receive transrectal
treatment. After 2 transrectal treatments and 7 physical therapy treatments focusing on exercise training
for strengthening, muscle lengthening, and external tender point release, patient 2 had achieved a 50%
reduction in pain intensity and a
slight relief of urgency at the time of
discharge. Given that he responded
well to the first 2 transrectal physical
therapy treatments for tender point
release, patient 2 chose to have his
wife perform the internal tender
point release at home. Studies indicate that training and clinical experience are necessary for accurate
identification of tender points.32,61
The patient felt that his wife had the
necessary skills to treat him at home.
The positive patient outcomes in this
case report are consistent with the
findings of several studies regarding
the effects of tender point release
to reduce painful symptoms in var-
ious locations throughout the
body.23,34,35,62– 64 Several self-help
approaches were used with both
patients, in addition to tender point
release. Whether the changes in outcome scores were due to tender
point release alone cannot be stated.
Adherence to the home program
was not monitored, and the impact
on the patients’ symptom reduction
is unknown.
Although this case report demonstrated patient improvement with a
multimodal physical therapy intervention that included manual therapy techniques applied to the pelvic
floor, the improvement cannot necessarily be attributed to the specific
manual therapy. The improvement
could have been related to the nonspecific effects of therapeutic touch
or placebo. Whether the positive
outcomes were due primarily to the
manual therapy techniques or to the
relaxation, flexibility, and aerobic
exercises is not known.
Further research comparing men diagnosed with CP/CPPS who receive
pelvic-floor manual physical therapy
alone with those who perform only
progressive muscle relaxation or aerobic exercise coupled with manual
therapy techniques applied to the
pelvic floor is necessary to determine whether manual therapy techniques applied to the pelvic floor
alone are superior in reducing pain
and restoring functional activity.
A multimodal physical therapy intervention that included manual therapy techniques applied to the pelvic
floor performed by a physical therapist, along with progressive muscle
relaxation, postural and flexibility
exercises, and aerobic exercises, appeared to be beneficial to both patients in reducing pain and improving sexual function.
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December 2010
Physical Therapist Management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome
Dr Van Alstyne and Dr Haskvitz provided
concept/idea/project design. All authors
provided writing. Dr Van Alstyne provided
patients. Dr Harrington provided clerical
support. Dr Harrington and Dr Haskvitz provided consultation (including review of
manuscript before submission).
This case report was completed in partial
fulfillment of Dr Van Alstyne’s Doctor of
Physical Therapy degree at The Sage
Colleges.
The authors received permission from the
Institutional Review Board of The Sage Colleges to write this report, and the report
meets all HIPAA requirements for this institution. In addition, the Department of Clinical Investigation at Walter Reed Army Medical Center gave permission to publish this
report.
A poster presentation of this work was given
at the Combined Sections Meeting of the
American Physical Therapy Association; February 6 –9, 2009; Las Vegas, Nevada.
The opinions or assertions contained herein
are the private views of the authors and are
not to be construed as official or as reflecting
the views of the Department of the Army or
the Department of Defense.
This article was submitted December 20,
2009, and was accepted July 16, 2010.
DOI: 10.2522/ptj.20090418
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Volume 90 Number 12
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Physical Therapist Management of Chronic
Prostatitis/Chronic Pelvic Pain Syndrome
Linda S. Van Alstyne, Kendra L. Harrington and Esther
M. Haskvitz
PHYS THER. Published online September 23, 2010
doi: 10.2522/ptj.20090418
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