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The Effectiveness of Manual
Therapy on Chronic Pelvic Pain:
An Evidence-Based Review
Jessica Manley, DPTc
PT 910 Evidence-Based Practice
Spring 2012
Pelvic Floor Musculature
The Roles of the Pelvic Floor
Support for
viscera
Respiration
Pelvic
floor
function
Sexual
function
Spinal
stability
Bowel and
bladder
function
Gentilcore-Saulnier et al. 2010, Fritsch et al. 2011
What is Chronic Pelvic
Pain?
Bowel
and bladder
dysfunction
Pain in the pelvis or
lower abdomen
Sexual
dysfunction
CPP
Pain with
urination/defecation
Pain with sex
Anxiety
and
depression
Anderson et al. 2011,
FitzGerald et al. 2009, Heyman et al. 2006,
Montenegro et al. 2010, Maigne et al. 2006,
Oyama et al. 2004, Figuers et al. 2010
Significance of CPP
Prevalence: 14.7% - 25% women and men
60-95% women and men with refractory CPP
$881 million to $2 billion per year in the US
Alappattu 2011, Stones et al. 2010, Montenegro 2007, Mathias et al. 1996, Tu et al. 2005
Causes of CPP
Mechanical
abnormalities
Visceral pain
Repetitive
minor
trauma
Visceral
disease
Trauma
Chronic
holding
patterns
CPP
Pain anxiety
Alappattu 2011, Hoffman 2011, Anderson 2002, Gerwin 2002, Jarrell 2008, Wu et al. 2009
Current Treatment of CPP
Surgery
Pharmacology
Psychotherapy
Manual Therapy
Laparoscopy
Hormone therapy
Psychotherapy
Static magnetic
therapy
Laparotomy
Tricyclic
Antidepressants
Writing in a diary
PFM manual therapy?
Coccygectomy
SSRIs
Local injection
Botox injection
Roth 2011, Stones et al. 2010, Butrick 2009, Patijn et al. 2010
The CPP Cycle
Hypertonic PFM
Sustained
muscle activity
Myofascial
trigger points
Pain anxiety
Prevents normal
resting tone
PFM
dysfunction
Weiss 2001, Montenegro et al. 2008, Chaitow 2007
Relevance to PT
Test and
measure
incontinence
Myofascial
trigger point
release
(MFR)
Muscle
length of
PFM
Toileting
position
PT
Muscle
performance
of PFM
Pauls and Shelly, 1999
PFM Manual Therapy
• PFM Manual Therapy:
Compression,
contract/relax stretching
and STM of myofascial
trigger points
• Abdominal wall, back,
buttocks, thighs, and PFM
transrectally or
transvaginally
• Thiele Massage: massage
from origin to insertion
along the direction of the
PFM
Butrick
Weiss 2009
2001
Gap in Literature
No current reviews on
manual therapy for
the treatment of men
and women with CPP
Little guidance to PTs
on effective treatment
for these symptoms
Purposes
Primary Purpose
• Is manual therapy effective at reducing pain for men
and women with CPP symptoms?
• This is a foreground question.
Secondary Purpose
• Is manual therapy more effective than a control or
comparison group at reducing pain for men and
women with CPP symptoms?
PICO
P
• Acyclic
• Inflammatory or
noninflammatory
pelvic pain
• Lower
abdominal pain
• Urogenital pain
• > 1 month
• Not associated
with pregnancy
I
• PFM manual
therapy
• Thiele Massage
C
• Control
• General, nonspecific
massage
• Counseling
• Short-form
wave therapy
(magnetic)
O
• Visual Analog
Scale (VAS) for
pain
Hypotheses
First Null Hypothesis:
• Manual therapy is not effective in reducing pain in patients with CPP
First Alternative Hypothesis:
• Manual therapy is an effective treatment for reducing pain for patients
with CPP
Second Null Hypothesis:
• Manual therapy has no effect on pain reduction when compared to a
control or comparison group
Second Alternative Hypothesis:
• Manual therapy has an effect on pain reduction when compared to a
control or comparison group
Expected Findings
10-20 articles on manual therapy for CPP
Statistically significant reduction in pain with
manual therapy interventions
Statistically significant difference in pain with
manual therapy interventions when compared to
control or comparison groups
Methods: Criteria
Inclusion Criteria
Exclusion Criteria
• PFM Manual
therapy
• Outcome
measurement of
pain with the visual
analog scale (VAS)
• English
• Human studies
• Incorporation of
other therapies
(chiropractic
manipulation, drug
therapy, surgery,
dry needling)
• Perinatal subjects
• Case reports
Methods
Databases searched
• PubMed
• Cochrane Library
• CINAHL
Search terms
• Thiele massage, physiotherapy, manual therapy, physical
therapy, trigger point, or myofascial and coccydynia,
perineal, pudendal neuralgia, prostatitis, chronic pelvic
pain, pelvic floor, pelvic pain, levator ani, interstitial
cystitis, coccygodynia, or sexual dysfunction and pain.
Methods: Statistics
Analysis of reduction in pain via VAS:
•
•
•
•
Single group effect size
Two-group effect size
Q statistic with inverse variance for weighting
95% confidence intervals
Results: PRISMA Diagram
A secondary reviewer confirmed that the studies met the inclusion criteria
Results: Primary Articles
Author, Year
Type of Study
Level of
Evidence
FitzGerald, 2009
Single-Blind RCT
2b
Maigne, 2006
Randomized Case Control
3b
Heyman, 2006
Randomized Case Control
3b
Anderson, 2011
Case Series
4
Oyama, 2004
Case Series
4
Montenegro, 2010
Case Series
4
Figuers, 2010
Retrospective Case Series
4
Results: Population
Study
Patient
Population
Age
N
Diagnosis
Duration
FitzGerald, 2009
Females,
Males
43
44
IC/PBS
CP/CPPS
<3 years
Maigne, 2006
Females,
Males
45
100
Coccygodynia
13 months
Heyman, 2006
Females
34
44
CPP
29 months
Anderson, 2011
Males
48
116
CP/Orchialgia
4.8 years
Oyama, 2004
Females
42
13
IC
5-14 years
Montenegro, 2010
Females
36
6
CPP
>6 months
Figuers, 2010
Females
52
5
CPP
13 years
Results: Population
Patient Characteristic
Average Across Studies
Males
45%
Female
55%
Age
42.9 years
Symptom Duration Range 6 months to 14 years
Results: Intervention
Study
Intervention
Frequency/Duratio
n
Follow Up
FitzGerald,
2009
Manual stretching PFM,
MFR of PFM
10 visits, 30-60 mins
12 weeks
Maigne, 2006
Manual stretching PFM
3 visits, 5 mins
12 weeks
Heyman,
2006
Manual stretching PFM
2 visits, 5 mins
4 weeks
Anderson,
2011
MFR to PFM
5 visits, 60 mins
4-6 weeks
Oyama, 2004
Thiele massage
10 visits, 5 mins
6 months
Montenegro,
2010
Thiele massage
4 visits, 5 mins
5-7 weeks
Figuers, 2010
MFR to PFM
3-15 visits
4 weeks
Single Group Effect Size for Pain VAS
Q Statistic: 35.67
Random Effects
Model
Statistically
Significant!
-1.28 (-1.93, -0.63)
Two Group Effect Size for Pain VAS
Q Statistic: 14.28
Random Effects
Model
Not statistically
significant
-0.72 (-1.44, 0.004)
Discussion
Able to reject first null hypothesis!
• Manual therapy is effective
• Effect size is large
• Clinically crucial effect
Cohen 1988
Discussion
Unable to reject second null hypothesis
• Manual therapy is not statistically effective as an
intervention when compared to control groups
Clinical Significance
Single group effect size
• Change in VAS: Decreased by 2.56 points
Two group effect size
• Change in VAS: Difference between groups of 1.77
points
MCID in endometriosis
• 1 point change on 0-10 scale
Gerlinger et al. 2010
Two Group Effect Size for Pain VAS
Q Statistic: 14.28
Random Effects
Model
Not statistically
significant
-0.72 (-1.44, 0.004)
Current Treatment of CPP
Surgery
Pharmacology
Psychotherapy
Manual Therapy
Laparoscopy
Hormone therapy
Psychotherapy
Static magnetic
therapy
Laparotomy
Tricyclic
Antidepressants
Writing in a diary
PFM manual therapy
Coccygectomy
SSRIs
Local injection
Botox injection
Roth 2011, Stones et al. 2010, Butrick 2009, Patijn et al. 2010
Harm/Adverse Events
4 articles mentioned adverse events
• Increase in pain from manual therapy
Potential harm of other interventions vs.
manual therapy
• Surgical complications
• Medication side effects
Cost
None of the articles specifically address cost
No direct cost increase
• Training for PTs in PFM manual therapy
• Feasibility at a clinical site
Improvement with brief duration of treatment
• 4 of 8 studies used 5 min treatment sessions
Implications for Clinical Practice
Address this issue!
• 70% of women diagnosed with endometriosis report that at least 1
physician has claimed their symptoms were due to psychological
disturbance
What specifically should YOU do?
• Ask patients about pain in this area
• Possible questionnaires: McGill Questionnaire
• Refer as necessary!
Roth 2011, Stones et al. 2010, Montenegro 2007
Limitations
Articles in English available to author
High Q statistic, heterogeneity in articles
• Different manual therapy techniques
• Different diagnoses
Lack of functional outcomes
Pathogenesis of CPP is poorly understood
Future Work
More studies on PFM manual therapy
• CPP diagnosis
• Functional outcomes
• Intervention frequency/duration
Conclusion
PFM manual therapy is a low risk, effective
intervention for pain associated with CPP
Thank You!
• Amy Selinger, PT, DPT, OCS
• Jeannette Lee, PT, PhD
• Diane Allen, PT, PhD
• Brianna Pickering, DPTc
• Justin Trumbull, DPTc
• USCF/SFSU Faculty
• UCSF/SFSU Class of 2012
References
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Questions?