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Targeted physical therapies help more chronic pelvic pain patients.

ORLANDO--Significantly more patients with chronic pelvic pain respond to targeted manual physical therapies, compared with global therapeutic massage, according to pilot results of a randomized, multicenter study.

Targeted manual physical therapies yielded significant improvements for patients with urologic chronic pelvic pain syndromes, including interstitial cystitis/painful bladder syndromes in men women and chronic prostatitis/chronic pelvic pain syndrome in men.

"Tension and tenderness of the pelvic floor musculature are frequently present in these patients and may play a role in the pain," Dr. Kenneth Peters said at the annual meeting of the American Urological Association.

Therapists skilled in myofascial physical therapy techniques, including connective tissue manipulation and myofascial trigger point release, often treat these patients, Dr. Peters said. However, no randomized, controlled trials or prospective studies had been done previously to support such internal and external pelvic floor myofascial physical therapies for these conditions.

Dr. Peters and his associates enrolled 47 patients in a multicenter study. Participants were randomized to 10 weekly sessions of 1 hour of either targeted physical therapy or global therapeutic massage (a nonspecific, somatic, full-body Western-style massage). Dr. Peters presented the pilot results on behalf of the Urological Pelvic Pain Collaborative Research Network. The study was supported by the National Institutes of Health and the National Institute of Diabetes and Digestive and Kidney Diseases.

The study included 23 men and 24 women; 1 patient withdrew from the manual physical therapy group and 2 withdrew from the global therapeutic massage group, leaving 44 patients who completed the study. Intrarectal myofascial release was used in men and intravaginal release in women in the directed therapy group. This is done by placing a finger in either the rectum or vagina and palpating the muscles on the internal sidewalls of the pelvis, Dr. Peters said. During this technique, patients are asked if these areas are tender.

Mean age was 43 years, and 87% of the participants were white. All patients reported 3 years or less of chronic pelvic pain. Moderate to severe baseline symptoms included pain in 96%, urinary urgency in 91%, and increased urinary frequency in 89%.

"The pelvic exam was key," Dr. Peters said. For a patient to be eligible for the trial, a clinician first determined if there was tenderness on the musculature or trigger points of a pelvic floor exam. Therapists then performed a second, confirmatory examination.

Therapists concurred with physicians 100% of the time. 'As physicians, we were able to identify the appropriate patients," said Dr. Peters, director of research, Ministrelli Program for Urologic Research and Education, department of urology, William Beaumont Hospital, Royal Oak, Mich.

The physical therapists routinely treated patients with chronic pelvic pain but were trained to use standardized techniques. Connective tissue manipulation of external tissue of the lower limbs, buttocks, abdominal wall, and pelvic floor was a common intervention, as well as trigger-point treatments to the abdominal wall and the pelvic floor. The trigger points are specific, tender areas on muscle groups that typically worsen the patient's underlying pain symptoms.

Response was graded on the 7-point Global Response Assessment scale. Patients who scored their overall symptoms as moderately or markedly better were considered responders. A total of 13 patients (57%) in the targeted manual physical therapy and 5 patients (21%) in the global therapeutic massage group met this definition, a statistically significant difference. "The overall response rate of 57% ... suggests that manual physical therapy might be a clinically meaningful treatment option for these patients," Dr. Peters said.

Adverse events, primarily pain, were reported by 52% of the manual physical therapy patients and 21% of the global therapeutic massage patients. Dr. Peters said, "No pain, no gain. Many of these people have pain during the therapy, but feel better afterward."

Because this was a pilot study, there were not enough patients to conclusively evaluate the efficacy of manual physical therapy, Dr. Peters said.


Miami Bureau
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Author:McNamara, Damian
Publication:OB GYN News
Article Type:Clinical report
Date:Jul 15, 2008
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