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

Oyama, 2004

Case Series

Montenegro, 2010

Case Series

Figuers, 2010

Retrospective Case Series

Results: Population
Study

Patient
Population

Age

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

CPP

>6 months

Figuers, 2010

Females

52

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
1.

Gentilcore-Saulnier E, McLean L, Goldfinger C, Pukall CF, Chamberlain S. Pelvic floor muscle assessment outcomes in women with and without
provoked vestibulodynia and the impact of a physical therapy program. J Sex Med. 2010;7(2 Pt 2):1003-22. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/20059663. Accessed January 5, 2012.
2. Fritsch H, Zwierzina M, Riss P. Accuracy of concepts in female pelvic floor anatomy: facts and myths! World J Urol. 2011. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/22002833. Accessed January 5, 2012.
3. Anderson RU, Wise D, Sawyer T, Glowe P, Orenberg EK. 6-day intensive treatment protocol for refractory chronic prostatitis/chronic pelvic pain
syndrome using myofascial release and paradoxical relaxation training. J Urol. 2011;185(4):1294-9. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/21334027. Accessed November 18, 2011.
4. FitzGerald MP, Anderson RU, Potts J, 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. Available at:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2872169&tool=pmcentrez&rendertype=abstract. Accessed December 3, 2011.
5. Heyman J, Ohrvik J, Leppert J. Distension of painful structures in the treatment for chronic pelvic pain in women. Obstet Gynecol. 2006;85(5):599-603.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/16752240. Accessed January 4, 2012.
6. Montenegro MLLDS, Mateus-Vasconcelos EC, Candido dos Reis FJ, et al. 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. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20590980.
Accessed January 4, 2012.
7. Maigne J-Y, Chatellier G, Faou ML, Archambeau M. The treatment of chronic coccydynia with intrarectal manipulation: a randomized controlled
study. Spine. 2006;31(18):E621-7. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16915077.
8. Figuers CC, Amundsen CL, Weidner AC, Hendricks CK, Holladay CL. Physical Therapist Interventions for Voiding Dysfunction and Pelvic Pain: A
Retrospective Case Series. Phys Ther. 2010;34(2):40-44.
9. Oyama I a, Rejba A, Lukban JC, 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. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15533464. Accessed October 12, 2011.
10. Haugstad GK, Haugstad TS, Kirste UM, et al. Mensendieck somatocognitive therapy as treatment approach to chronic pelvic pain: results of a
randomized controlled intervention study. Am J Obstet Gynecol. 2006;194(5):1303-10. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16647914.
Accessed September 26, 2011.
11. Haugstad GK, Haugstad TS, Kirste UM, et al. Continuing improvement of chronic pelvic pain in women after short-term Mensendieck somatocognitive
therapy: results of a 1-year follow-up study. Am J Obstet Gynecol. 2008;199(6):615.e1-8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18845283.
Accessed October 2, 2011.
12. Alappattu MJ, Bishop MD. Psychological factors in chronic pelvic pain in women: relevance and application of the fear-avoidance model of pain. Phys
Ther. 2011;91(10):1542-50. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3185223&tool=pmcentrez&rendertype=abstract.
Accessed April 15, 2012.

References
13. Hoffman D. Understanding multisymptom presentations in chronic pelvic pain: the inter-relationships between the viscera and myofascial pelvic floor
dysfunction. Curr Pain Headache R. 2011;15(5):343-6. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21739128. Accessed March 8, 2012.
14. Gerwin RD. Myofascial and Visceral Pain Syndromes: Visceral-Somatic Pain Representations. Imprint. 2002;10(1):165-175.
15. Butrick CW. Pelvic floor hypertonic disorders: identification and management. Obstet Gynecol Clin North Am. 2009;36(3):707-22.
16. Patijn J, Janssen M, Hayek S, et al. 14. Coccygodynia. Pain Practice. 2010;10(6):554-9. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20825565.
17. Jarrell J. Gynecological pain, endometriosis, visceral disease, and the viscero-somatic connection. J Musculoskelet Pain. 2008;16(1-2):21-27.
18. Travell JG, Simons DG, Simons LS. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2. Lippincott Williams & Wilkins; 1998.
19. Chaitow L. Chronic pelvic pain: Pelvic floor problems, sacroiliac dysfunction and the trigger point connection. J Bodywork Mov Ther. 2007;11:327-339.
20. Gottsch HP, Yang CC, Berger RE. A review of botulinum toxin use for chronic pelvic pain syndrome. Curr Urol Rep. 2010;11(4):265-70.
21. Stones W, Cheong Y, Howard F, Singh S. Interventions for treating chronic pelvic pain in women ( Review ). Cochrane Db Syst Rev. 2010;(11).
22. Tu FF, As-Sanie S, Steege JF. Musculoskeletal Causes of Chronic Pelvic Pain: A Systematic Review of Existing Therapies: Part II*. Obstet Gynecol Surv.
2005;60(7):474-483.
23. Phillips B, Ball C, Sackett D, et al. Oxford Centre for Evidence-based Medicine Levels of Evidence. University of Oxford. 2009;(November 1998):4-5.
Available at: http://www.cebm.net/index.aspx?o=1025.
24. Van Alstyne LS, Harrington KL, Haskvitz EM. Physical therapist management of chronic prostatitis/chronic pelvic pain syndrome. Phys Ther.
2010;90(12):1795-1806. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22211156.
25. Montenegro MLLS, Vasconcelos ECLM, Candido Dos Reis FJ, Nogueira a a, Poli-Neto OB. Physical therapy in the management of women with
chronic pelvic pain. Int J Clin Prac. 2008;62(2):263-9.
26. Pauls J, Shelly E. Applying the Guide to Physical Therapist Practice to women's health physical therapy. Journal of the Section on Women's Health.
1999;23(3):8-12.
27. Anderson RU, Wise D, Sawyer T, Chan C a. Sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: improvement after
trigger point release and paradoxical relaxation training. J Urol. 2006;176(4 Pt 1):1534-8; discussion 1538-9. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/16952676. Accessed January 6, 2012.
28. Weiss JM. Pelvic floor myofascial trigger points: Manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. 2001;166(6):22262231. Available at: http://linkinghub.elsevier.com/retrieve/pii/S0022534705655395. Accessed January 22, 2012.
29. Dommerholt J, Bron C, Franssen J. Myofascial Trigger Points: An Evidence-Informed Review. J Man Manip Ther. 2006;14(4):203-221.
30. Roth RS, Punch M, Bachman JE. Psychological factors in chronic pelvic pain due to endometriosis: a comparative study. Gynecol Obstet Invest.
2011;72(1):15-9. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21606636. Accessed April 12, 2012.
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. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15947608. Accessed January 4, 2012.

Questions?