Physiotherapy and Pelvic Pain?

physiotherapy-pelvic In patients with pelvic pain conditions, these muscles may be tight or in spasm, have a combination of tightness and weakness, or have pain-triggering spots called “trigger points.”

Pain “referred” from internal organs, such as the bladder, may set off these muscle problems, but the muscle problems themselves can also set off bladder symptoms. Pain can also be “referred” to the skin and other muscles, such as in your lower abdomen, lower back, buttocks, thighs, and perineal area. 

Physical therapy techniques help relax and lengthen tight muscles and release trigger points.

Here is a great article on what physical therapy can do for pelvic floor pain and disorders by Carolina Pelvic Health.

What to Expect 

When you start working with a knowledgeable PT, they will usually do an assessment before starting therapy. Assessment can include looking for external muscle problems and an internal exam. 

Your PT may also look at how you stand, walk, and sit in order to judge whether your joints and posture may affect your pelvic floor. Bone and muscle problems in your lower back, hips, sacroiliac joint, buttocks, or thighs can stress your pelvic floor muscles, contributing to your pelvic pain.

The Internal Exam

After obtaining your informed permission, the internal exam follows. The physical therapist inserts her gloved, lubricated index finger intravaginally, up to the level of the pelvic floor muscles, approximately one inch from the vaginal opening. She will feel for tissue excursion (whether one side is more flexible than the other side, checking for tension and resistance), again noting pain, adhesionstrigger points, and whether her palpation over specific muscles reproduces your symptoms. For an example, when the therapist presses on a trigger point on one of my pelvic floor muscles I can feel a burn in my uretha. It is such an AHA moment!

Muscle-strength testing of the pelvic floor follows, with the therapist’s index finger remaining internally to feel for quality of your pelvic muscle contraction. She will measure how strong your pelvic floor muscles are, whether your muscle can maintain that strong contraction up to 10 seconds, and typically whether all this be done up to 10 times.

Biofeedback testing may be next. Biofeedback measures the electrical activity of the muscle and transmits that information to either a range of numbers and/or sounds. The patient sees the numbers and learns how to retrain her pelvic-floor muscles with the guidance of the physical therapist. It really is amazing. As I can make my numbers go from a 4 to a 1.8 or less just by mentally telling myself to relax. You don’t think you’re clenching your floor, but typically we do!

The therapist may measure pelvic floor contractions with a perineometer, a small, tampon-like device with sensors, placed into the vagina or rectum(the width and length of a female index finger) slowly and with your conscious use of breath. These sensors pick up the electrical activity of your pelvic floor muscles.

Your therapist will measure the electric voltage (microvolts) that your pelvic-floor muscles elicit during rest, during slight contraction, and then during full contraction. She will measure if your muscle returns to complete baseline rest following contractions, whether your muscles have good endurance etc. She may use the information obtained through Biofeedback to help you learn how to properly recruit your pelvic muscles and regain normal function.

I love this from Pelvic Pain Rehab – the following is what they do in a typical appointment! Please check them out, they have wonderful information for pelvic floor pain sufferers on their site.

The first thing we’ll do during treatment is to treat the patient’s connective tissue. The reason we do the connective tissue manipulation first is that it makes it easier to treat underlying trigger points, it calms the nervous system down some; it increases blood flow to the area; and it relaxes the pelvic floor a bit.

For the most part, there are four rungs to the ladder of pelvic pain treatment. They are: working out external trigger points, working out internal trigger points and lengthening tight  muscles, connective tissue manipulation, and treating at structural abnormalities. However, the last, treating structural abnormalities, is only incorporated when it applies. So during a typical appointment, we are focused on these strategies.

Typically we spend about half the appointment on connective tissue manipulation and external trigger point release (external work), and half the appointment on internal trigger point release and muscle lengthening (internal work). An appointment lasts for one hour. And patients either see us twice a week or once a week.

So that’s what we do during a typical PT appointment. What we don’t do during an appointment is: We don’t ever leave our patients alone in the room hooked up to a tens unit or to a biofeedback machine or performing exercises with an aide. When it comes to the successful treatment of pelvic pain, what works is manual, hands-on treatment, so that’s what we do.

Also, we don’t use a cookie cutter, one-size-fits-all approach to pelvic pain PT. Not only will every patient’s treatment be different, but a specific patient’s treatment will change and evolve from appointment to appointment!

I can’t stress enough that NOT all physical therapists are the same!

Hands-On Therapy

Physical Therapy for pelvic pain is a hands-on treatment. It will include both external and internal techniques, although therapists will not use internal techniques until you are comfortable with them. External techniques may include:

  • skin rolling
  • deep tissue massage, often called “myofascial release”
  • trigger-point therapy to release tight spots or “knots”
  • nerve release
  • joint mobilization

To treat your pelvic floor internally, the therapist may insert a finger or an appropriate instrument in the vagina or rectum to massage the muscles and connective tissue directly and to release trigger points. A common trigger point release technique is to put pressure on the spot until it relaxes. Internal massage can also help to release nerves. PT’s have to be specially trained and certified in Canada to do this.

This following paragraph will make more sense if you are acquainted with pelvic floor anatomy or are a pelvic floor nerd. I am including it as it wonderfully described the fact finding mission of a Pelvic Floor Therapist. Pelvic Floor Spasm by 

Pelvic examination to investigate acute or chronic pelvic pain should always include single-digit palpation of at least the levator ani and piriformis muscles. Begin by palpating the introitus to rule out vaginismus and then move to the iliococcygeus and pubococcygeus muscles bilaterally, with specific attention to findings of banding, spasm, or tenderness. Spasm of a portion of the levator ani is often detected as a palpable band resembling a guitar string within the muscle or focal trigger points. Examine the piriformis with the finger pressed posterolaterally and superior to the ischial spine. In the patient with normal pelvic floor musculature, palpation of the levator ani and piriformis typically elicits a sensation of pressure, whereas a patient with pelvic floor myalgia will report significant pain. The discomfort elicited in such patients often reproduces the primary complaint. Another typical finding during examination is a distinct asymmetry between the right and left elements of the pelvic diaphragm.This shortening or contracture will be ipsilateral to the patient’s pain.

Methods of Treatment

PTs also use a variety of devices to help you learn to relax your pelvic floor or to treat your pelvic pain directly.

  • Biofeedback uses electrodes placed on your body (on the perineum and/or the area around the anus) or probes inserted in the vagina or rectum to sense how tense or relaxed your pelvic floor muscles are and display the results on a computer or other device. These cues can help you learn to relax those muscles. 
  • Electrical Stimulation stimulates your pelvic floor muscles directly through a small probe inserted into the vagina or rectum. This may help desensitize nerves or even cause muscles to contract and relax. Stimulation through electrodes placed on your body may be used to calm pain and spasms. These units can be used at home.
  • Interferential Therapy is a kind of electrical stimulation delivered from electrodes placed on the skin. The impulses “interfere” with each other at the point of pain deep in tissues and can replace and relieve the sensations of spasm. These units can be used at home.
  • Ultrasound uses high-frequency sound waves applied through a wand or probe on your skin to produce an internal image or to help treat pain. Real-time ultrasound can let you see your pelvic floor muscles functioning and help you learn to relax them. Therapeutic ultrasound uses sound waves to produce deep warmth that may help reduce spasm and increase blood flow or, on a nonthermal setting, may promote healing and reduce inflammation.

Here is a fantastic educational video on Physiotherapy and Pelvic Pain from BC Women’s Health Centre

Physical Therapy is an Effective Treatment for Endometriosis – well worth reading for all types of pelvic floor pain help