Kronik Pelvik Ağrı: Pelvik Tabana Özgü Değerlendirme ve Manuel Yaklaşımlar

Yıl 2021, Cilt: 3 Sayı: 2, 103 - 113, 04.07.2021

Kübra Sağır , Ebru Kaya Mutlu

Öz

Muskuloskeletal nedenlere dayanan kronik pelvik ağrı (KPA) özellikle pelvik taban olmak üzere abdominal duvar, pelvik kuşak ve lumbal bölgede yumuşak doku disfonksiyonları ve tetik noktalar ile karakterizedir. Manuel bir uygulamaya veya kuvvetlendirme programına başlamadan önce intravajinal muayene ile pelvik taban kaslarının tonus, kuvvet ve enduransı değerlendirilir. KPA’da pelvik taban kasları genellikle aşırı aktif olup gergin bant ve tetik noktalar barındırır. Aşırı aktif ve hipoaktif pelvik tabanın tedavisi oldukça farklılık göstereceğinden tedavi programı muayene bulgularına göre şekillendirilmelidir. Fizyoterapi, bu alandaki uluslararası derneklerin yayınlamış olduğu rehberlerde ve bağımsız derlemelerde KPA için bir tedavi seçeneği olarak yer almaktadır. Manuel terapi uygulamaları bir görüş birliği oluşturacak kanıt düzeyine sahip olmamasına rağmen böylesine karmaşık bir kronik ağrı sendromunda tedavi için bir alternatif oluşturmakta ve ümit vadetmektedir. Literatürde pelvik tabanda iskemik kompresyon, miyofasyal gevşetme ve postizometrik relaksasyon tekniklerinin kombine kullanımı, abdominal duvar ve pelvik kuşakta tetik nokta deaktivasyonu ve thiele masajının etkileri gösterilmektedir. Manuel terapi uygulamaları sadece pelvik taban ile sınırlı kalmamalı, abdominal duvar, pelvik kuşak, alt ekstremiteler de tedavi programına dahil edilmelidir. Postür, dizilim bozuklukları ve solunum paternleri de göz önünde bulundurulmalıdır. Manuel terapi uygulamaları, uygun egzersizlerle kombine edilerek, endikasyon gösteren hastaların seçilmesi ile muskuloskeletal KPA tedavisinde kilit rol oynayabilir.

Anahtar Kelimeler

İskemik kompresyon, Kronik pelvik ağrı, Manuel terapi, Pelvik taban muayenesi, Tetik nokta, Thiele masajı

Destekleyen Kurum

Yoktur

Proje Numarası

Yoktur

Teşekkür

Yoktur

Chronic Pelvic Pain: Pelvic Floor-Specific Evaluation and Manual Approaches

Öz

Musculoskeletal chronic pelvic pain (CPP) is characterized by soft tissue dysfunctions and trigger points in the abdominal wall, lumbar region, pelvic girdle and floor. Before starting a manual practice or strengthening program, the pelvic floor muscles are evaluated with an intravaginal examination. In CPP, pelvic floor muscles are generally overactive and contain tight bands and trigger points. Since the treatment of the pelvic floor, whose muscle tone is overactive or hypoactive, differs considerably, the treatment program should be planned according to the examination findings. Physiotherapy is included as a treatment option for CPP in guidelines published by international associations and independent reviews. Although manual therapy practices do not have the level of evidence to create a consensus, it provides a promising alternative for treatment in such a complex chronic pain syndrome. The literature shows the effects of combined use of ischemic compression, myofascial release, and post isometric relaxation techniques in the pelvic floor; trigger point deactivation in the abdominal wall and pelvic girdle; and the Thiele massage. Manual therapy practices should not only be limited to the pelvic floor, but also the abdominal wall, pelvic girdle, and lower extremities should be included in the treatment program. Additionally, posture, malalignment, and respiratory patterns should be considered. Manual therapy practices, by combining with appropriate exercises and selecting patients showing indications; may play a key role in the treatment of musculoskeletal CPP.

Anahtar Kelimeler

Chronic pelvic pain, Ischemic compression, Manual therapy, Pelvic floor examination, Trigger points, Thiele massage

Proje Numarası

Yoktur

Kaynakça

• Andrews J, Yunker A, Reynolds WS, Likis FE, Sathe NA, Jerome RN. Noncyclic chronic pelvic pain therapies for women: comparative effectiveness. 2012;
• Green-top Guideline. The Initial Management of Chronic Pelvic Pain. R Coll Obstet Gynaecol. 2012;41:1–16.
• Vincent K. Chronic pelvic pain in women. Postgrad Med J. 2009;85(999):24–9.
• Engeler D, Baranowski AP, Berghmans B, Borovicka J, Cottrell AM, Dinis-Oliveira P, et al. EAU Guidelines on Chronic Pelvic Pain 2020. Eur Assoc Urol Guidel 2020 Ed [Internet]. 2020;presented. Available from: http://uroweb.org/guideline/chronic-pelvic-pain/ LK - Chronic Pelvic Pain Uroweb%7Chttp://uroweb.org/guideline/chronic-pelvic-pain/%7C FG - 0
• Ahangari A. Prevalence of Chronic Pelvic Pain Among Women: An Updated Review. Pain Physician,. 2014;
• Özdemir K. Sakarya İlinde Yaşayan 15-49 Yaş Grubu Kadınlarda Kronik Pelvik Ağrının Prevalansı, Risk Faktörleri ve Yaşam Kalitesine Etkisi. Eskişehir Osmangazi Üniversitesi Sağlık Bilim Enstitüsü Doğum ve Kadın Sağlığı Hemsireliği Yüksek Lisans Tezi Eskişehir. 2012;
• Koyuncu T, Öz F, Ünsal A, Arslantaş D. ALPU’DA 18-64 YAŞ GRUBU KADINLAR ARASINDA KRONİK PELVİK AĞRI SIKLIĞI VE KAYGI DÜZEYİ. In: 15 Ulusal Halk Sağlığı Kongresi. 2012.
• Bradley MH, Rawlins A, Brinker CA. Physical Therapy Treatment of Pelvic Pain. Phys Med Rehabil Clin N Am [Internet]. 2017;28(3):589–601. Available from: http://dx.doi.org/10.1016/j.pmr.2017.03.009
• Spitznagle TM, Robinson CM. Myofascial pelvic pain. Obstet Gynecol Clin. 2014;41(3):409–32.
• Gerwin RD, Dommerholt J, Shah JP. An expansion of Simons’ integrated hypothesis of trigger point formation. Curr Pain Headache Rep. 2004;8(6):468–75.
• Simons DG. New views of myofascial trigger points: etiology and diagnosis. Arch Phys Med Rehabil. 2008;89(1):157–9.
• Srinivasan R, Greenbaum DS. Chronic abdominal wall pain: a frequently overlooked problem. Practical approach to diagnosis and management. Am J Gastroenterol. 2002;97, 4, 824.
• Engeler D, Baranowski A, Borovicka J, Cottrell A, Dinis-Oliveira P, Elneil S., et al. EAU Guidelines on chronic pelvic pain. Eur Assoc Urol. 2017;
• Nagpal AS, Moody EL. Interventional Management for Pelvic Pain. Phys Med Rehabil Clin N Am [Internet]. 2017;28(3):621–46. Available from: http://dx.doi.org/10.1016/j.pmr.2017.03.011
• FitzGerald MP, Kotarinos R. Rehabilitation of the short pelvic floor. I: Background and patient evaluation. Int Urogynecol J. 2003;14(4):261–8.
• Lukban J. The effect of manual physical therapy in patients diagnosed with interstitial cystitis, high-tone pelvic floor dysfunction, and sacroiliac dysfunction. Urology. 2001;57(1):121–2.
• Tuttle LJ, Nguyen OT, Cook MS, Alperin M, Shah SB, Ward SR, et al. Architectural design of the pelvic floor is consistent with muscle functional subspecialization. Int Urogynecol J. 2014;25(2):205–12.
• Kuner R. Central mechanisms of pathological pain. Nat Med. 2010;16(11):1258–66.
• Quaghebeur J, Wyndaele J-J. Chronic pelvic pain syndrome: role of a thorough clinical assessment. Scand J Urol. 2015;49(2):81–9.
• Nickel JC, Shoskes DA. Phenotypic approach to the management of the chronic prostatitis/chronic pelvic pain syndrome. BJU Int. 2010;106(9):1252–63.
• Davis SNP, Binik YM, Amsel R, Carrier S. Is a sexual dysfunction domain important for quality of life in men with urological chronic pelvic pain syndrome? Signs “UPOINT” to yes. J Urol. 2013;189(1):146–51.
• Chaitow L. Chronic pelvic pain: Pelvic floor problems, sacro-iliac dysfunction and the trigger point connection. J Bodyw Mov Ther. 2007;11(4):327–39.
• Brink CA, Wells TJ, Sampselle CM, Taillie ER, Mayer R. A digital test for pelvic muscle strength in women with urinary incontinence. Nurs Res. 1994;43(6):352–6.
• Laycock J. Incontinence. Pelvic floor re-education. Nursing (Lond). 1991;4(39):15–7.
• Isherwood PJ, Rane A. Comparative assessment of pelvic floor strength using a perineometer and digital examination. BJOG An Int J Obstet Gynaecol. 2000;107(8):1007–11.
• Devreese A, Staes F, De Weerdt W, Feys H, Van Assche A, Penninckx F, et al. Clinical evaluation of pelvic floor muscle function in continent and incontinent women. Neurourol Urodyn. 2004;23(3):190–7.
• Slieker‐ten Hove MCP, Pool‐Goudzwaard AL, Eijkemans MJC, Steegers‐Theunissen RPM, Burger CW, Vierhout ME. Face validity and reliability of the first digital assessment scheme of pelvic floor muscle function conform the new standardized terminology of the International Continence Society. Neurourol Urodynamics Off J Int Cont Soc. 2009;28(4):295–300.
• Meister MR, Shivakumar N, Sutcliffe S, Spitznagle T, Lowder JL. Physical examination techniques for the assessment of pelvic floor myofascial pain: a systematic review. Am J Obstet Gynecol. 2018;219(5):497.e1-497.e13.
• Klotz SGR, Schön M, Ketels G, Löwe B, Brünahl CA. Physiotherapy management of patients with chronic pelvic pain (CPP): A systematic review. Physiother Theory Pract [Internet]. 2019;35(6):516–32. Available from: https://doi.org/10.1080/09593985.2018.1455251
• Simons DG. Understanding effective treatments of myofascial trigger points. J Bodyw Mov Ther. 2002;6(2):81–8.
• Fall M, Baranowski AP, Fowler CJ, Lepinard V, Malone-Lee JG, Messelink EJ, et al. EAU guidelines on chronic pelvic pain. Eur Urol. 2004;46(6):681–9.
• Loving S, Nordling J, Jaszczak P, Thomsen T. Does evidence support physiotherapy management of adult female chronic pelvic pain? A systematic review. Scand J Pain [Internet]. 2012;3(2):70–81. Available from: http://dx.doi.org/10.1016/j.sjpain.2011.12.002
• Fuentes-Márquez P, Cabrera-Martos I, Valenza MC. Physiotherapy interventions for patients with chronic pelvic pain: A systematic review of the literature. Physiother Theory Pract [Internet]. 2019;35(12):1131–8. Available from: https://doi.org/10.1080/09593985.2018.1472687
• Committee on Practice Bulletins-Gynecology. Chronic Pelvic Pain: ACOG Practice Bulletin, Number 218. Obstet Gynecol. 2020;135(3):e98–109.
• Von HEYMANN W. KRONİK PELVİK AĞRILAR ve CİNSEL ŞİDDET-MANUELTERAPİ. Bilim Tamamlayıcı Tıp Regülasyon ve Nöral Ter Derg. 10(3):1–4.
• Weiss JM. Pelvic Floor Myo Fa Scial Trigger Points : Manuai Therapy F or Interstitial Cystitis and the Urgen Cy-Frequ E N C Y Syndrome. 2001;166(December):2226–31.
• Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174(1):155–60.
• Wise D, Anderson RU. A headache in the pelvis: a new understanding and treatment for chronic pelvic pain syndromes. National Center for Pelvic Pain Research San Francisco, CA; 2012.
• FitzGerald MP, Anderson RU, Potts J, Payne CK, Peters KM, Clemens JQ, et al. Randomized Multicenter Feasibility Trial of Myofascial Physical Therapy for the Treatment of Urological Chronic Pelvic Pain Syndromes. J Urol. 2009;182(2):570–80.
• Fitzgerald MP, Payne CK, Lukacz ES, Yang CC, Peters KM, Chai TC, et al. Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. J Urol. 2012;187(6):2113–8.
• Hawk C, Long CR, Reiter R, Davis CS, Cambron JA, Evans R. Issues in planning a placebo-controlled trial of manual methods: Results of a pilot study. J Altern Complement Med. 2002;8(1):21–32.
• Montenegro MLLS, Braz CA, Rosa-e-Silva JC, Candido-dos-Reis FJ, Nogueira AA, Poli-Neto OB. Anaesthetic injection versus ischemic compression for the pain relief of abdominal wall trigger points in women with chronic pelvic pain. BMC Anesthesiol [Internet]. 2015;15(1):1–8. Available from: http://dx.doi.org/10.1186/s12871-015-0155-0
• Halder GE, Scott L, Wyman A, Mora N, Miladinovic B, Bassaly R, et al. Botox combined with myofascial release physical therapy as a treatment for myofascial pelvic pain. Investig Clin Urol. 2017;58(2):134.
• Thiele GH. Coccygodynia and pain in the superior gluteal region: and down the back of the thigh: causation by tonic spasm of the levator ani, coccygeus and piriformis muscles and relief by massage of these muscles. J Am Med Assoc. 1937;109(16):1271–5.
• Thiele GH. Coccygodynia: cause and treatment. Dis Colon Rectum. 1963;6(6):422–36.
• Oyama IA, Rejba A, Lukban JC, Fletcher E, Kellogg-Spadt S, Holzberg AS, et al. Modified Thiele massage as therapeutic intervention for female patients with interstitial cystitis and high-tone pelvic floor dysfunction. Urology. 2004;64(5):862–5.
• Holzberg A, Kellog-Spadt S, Lukban J, Whitmore K. Evaluation of transvaginal theile massage as a therapeutic intervention for women with interstitial cystitis. Urology. 2001;57(6):120.
• De Souza Montenegro MLL, Mateus‐Vasconcelos EC, Candido dos Reis FJ, Rosa e Silva JC, Nogueira AA, Poli Neto OB. Thiele massage as a therapeutic option for women with chronic pelvic pain caused by tenderness of pelvic floor muscles. J Eval Clin Pract. 2010;16(5):981–2.
• Silva APM da, Montenegro ML, Gurian MBF, Mitidieri AM de S, Lara LA da S, Poli Neto OB, et al. Perineal massage improves the dyspareunia caused by tenderness of the pelvic floor muscles. Rev Bras Ginecol e Obs. 2017;39(1):26–30.
• Haas NP, Hoppe JD, Scriba PC. Wissenschaftliche Bewertung osteopathischer Verfahren. Dtsch Arztebl. 2009;106(46):2325–34.
• Marx S. Das chronische Beckenschmerzsyndrom. Urologe. 2017;56(8):1008–16.
• Orrock PJ, Myers SP. Osteopathic intervention in chronic non-specific low back pain: a systematic review. BMC Musculoskelet Disord. 2013;14(1):1–7.
• Franke H, Hoesele K. Osteopathic manipulative treatment (OMT) for lower urinary tract symptoms (LUTS) in women. J Bodyw Mov Ther. 2013;17(1):11–8.
• Sillem M, Juhasz-Böss I, Klausmeier I, Mechsner S, Siedentopf F, Solomayer E. Osteopathy for endometriosis and chronic pelvic pain–a pilot study. Geburtshilfe Frauenheilkd. 2016;76(9):960.
• Wong YY, Smith RW, Koppenhaver S. Soft tissue mobilization to resolve chronic pain and dysfunction associated with postoperative abdominal and pelvic adhesions: A case report. J Orthop Sports Phys Ther. 2015;45(12):1006–16.