Physiotherapy Theory and Practice

An International Journal of Physical Therapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: http://www.tandfonline.com/loi/iptp20

Physiotherapy management of patients with

chronic pelvic pain (CPP): A systematic review

Susanne G. R. Klotz MSc, PT, HS, Mila Schön BSc, PT, Gesche Ketels BA, PT,
HE, Bernd Löwe MD & Christian A. Brünahl MD

To cite this article: Susanne G. R. Klotz MSc, PT, HS, Mila Schön BSc, PT, Gesche Ketels BA,
PT, HE, Bernd Löwe MD & Christian A. Brünahl MD (2018): Physiotherapy management of patients
with chronic pelvic pain (CPP): A systematic review, Physiotherapy Theory and Practice, DOI:
10.1080/09593985.2018.1455251

To link to this article: https://doi.org/10.1080/09593985.2018.1455251

Published online: 28 Mar 2018.

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PHYSIOTHERAPY THEORY AND PRACTICE
https://doi.org/10.1080/09593985.2018.1455251

REVIEW

Physiotherapy management of patients with chronic pelvic pain (CPP): A

systematic review
a,b
Susanne G. R. Klotz MSc, PT, HS , Mila Schön BSc, PTb, Gesche Ketels BA, PT, HEb, Bernd Löwe MDa,
and Christian A. Brünahl MDa
a
Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany and Schön
Klinik Hamburg Eilbek, Hamburg, Germany; bDepartment of Physiotherapy, University Medical Centre Hamburg-Eppendorf, Hamburg,
Germany

ABSTRACT ARTICLE HISTORY

Introduction: Chronic pelvic pain (CPP) is a common pain condition. However, treatment remains Received 10 June 2017
challenging. Musculoskeletal findings are frequent; therefore physiotherapy might be helpful. The Accepted 24 October 2017
purpose of this review was to evaluate the current evidence on physiotherapy in patients with Revised 5 September 2017
CPP (PROSPERO registration number CRD42016037516). Methods: Six databases were searched KEYWORDS
and additional hand searches were performed. Two reviewers independently conducted the Chronic pelvic pain;
database search and selected studies using a two-step approach. The methodological quality physiotherapy; systematic
was assessed applying the Critical Review Form – Quantitative Studies. Results: A total of eight review
studies were included. Trigger point therapy was examined in four studies; two of which were
randomized controlled trials. All studies indicate a significant change in pain measurement. The
other four studies evaluated the effect of biofeedback, Thiele massage, Mensendieck somatocog-
nitive therapy and aerobic exercises, whereas the last two were tested in controlled trials. All
studies showed significant improvements in pain assessment. Conclusions: The evidence cur-
rently available is sparse with methodological flaws, making it difficult to recommend a specific
physiotherapy option. There is an urgent need for high-quality randomized controlled trials to
identify the most effective physiotherapy management strategy for patients with CPP.

Introduction CPP is associated with high psychopathological find-

ings (Albrecht, Löwe, Brünahl, and Riegel, 2015; Brünahl
Chronic pelvic pain (CPP) is defined as chronic pain that
et al., 2014; Riegel et al., 2014) and lower quality of life
is perceived in pelvis-related structures and organs. If no
scores in both men and women (Barcelos, Conde, Deus,
apparent pathology or proven infection can be associated
and Martinez, 2010; Tripp and Nickel, 2010; Tripp et al.,
with the pain phenomenon, the occurring pain can be
2009). Shoskes, Nickel, Rackley, and Pontari (2009) iden-
labeled as CPP syndrome (Engeler et al., 2014). It is a
tified and grouped six clinical phenotypes in the UPOINT
common pain condition with a worldwide prevalence
classification using the domains Urinary, Psychosocial,
among women ranging from 2.1% to 26.6% (Ahangari,
Organ specific, Infection, Neurologic and Tenderness of
2014; Latthe et al., 2006) and among men from 2.0% to
skeletal muscles.
9.7% (Krieger et al., 2008; Ku, Kim, and Paick, 2005).
Treatment of these patients remains a challenge due
The clinical signs of CPP are varied and may relate
to the diverse clinical signs and phenotypes. Several
to sexual activity, urological symptoms and/or pain in
non-surgical as well as surgical strategies exist
various areas such as in the pubic region/bladder or
(Anothaisintawee et al., 2011; Yunker et al., 2012).
perineal region (Clemens et al., 2015). Although the
Additionally, complementary and alternative treat-
symptoms may be perceived in a specific region, the
ments have been considered in treating patients with
chronic pain condition should still be labeled CPP
CPP (Anothaisintawee et al., 2011; Carinci, Pathak,
rather than a specific subdivision due to the multifac-
Young, and Christo, 2013). At present, however,
torial etiology and the possible multisystem effects of
many of the therapy approaches seem to have only
the chronic pain (Engeler et al., 2014).
limited effect in managing CPP (Cohen et al., 2012).

CONTACT Susanne G. R. Klotz, MSc, PT, HS s.klotz@uke.de Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre
Hamburg-Eppendorf, Hamburg, Germany and Schön Klinik Hamburg Eilbek, Hamburg, Germany.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iptp.
© 2018 Taylor & Francis
2 S. G. R. KLOTZ ET AL.

The UPOINT classification might be helpful for direct- into groups based on the specific physical therapy
ing therapy according to phenotypes and thus resulting in method to provide an insight into their effect on
better outcomes (Shoskes, Nickel, and Kattan, 2010). The patients with CPP.
majority of patients had positive findings in more than
one domain, hence; a multidisciplinary treatment
approach should be used acknowledging psychosocial
Methods
and physical symptoms (Shoskes, Nickel, and Kattan,
2010). For patients with positive findings in the Database sources and searches
Psychosocial dysfunction domain, Shoskes, Nickel,
The review was registered in the international systema-
Rackley, and Pontari (2009) recommend psychosocial
tic review registry PROSPERO: CRD42016037516. A
treatment approaches. Various strategies like body aware-
systematic database search was conducted on 17th
ness, reflection and counseling are applied in patients
April 2017. The six electronic databases Cinahl,
with CPP (Champaneria et al., 2012).
Medline, PEDro, PsycINFO, SPORTDiscus and The
Physiotherapy is suggested for patients with posi-
Cochrane Library were searched for literature dating
tive findings in the tenderness of muscles domain
from the inception of the database up until April 2017.
(Shoskes, Nickel, Rackley, and Pontari, 2009), a diag-
Two independent searches were conducted by two
nosis that covers 53–64% of patients (Shoskes,
authors (SGRK). Each phrase of the search strategy
Nickel, Dolinga, and Prots, 2009; Shoskes, Nickel,
was looked up in the categories “title” and “abstract”
and Kattan, 2010). In these patients, painful myofas-
and, where possible, also in the keywords (Mesh and
cial trigger points can be found in the pelvic floor
Thesaurus) of the particular database. No filters were
muscles as well as in muscles of the abdominal wall,
used. Adaptations of the search strategy had to be made
the back, the gluteal region and/or the thighs
for databases that did not have subject headings and/or
(Anderson et al., 2009). Physiotherapy is not only
limitations in composition of search terms.
recommended by the UPOINT classification; the
In advance of the database search, the search strategy
European Association of Urology also includes it as
was determined in order to detect as many relevant
a treatment option in their guidelines for CPP
studies as possible. It was decided to use two groups
(Engeler et al., 2014) as well as other clinical guide-
of search-words: first, a group of words that were
lines (Jarrell et al., 2005; Royal College of
synonyms for the pain condition, and second, syno-
Obstetricians and Gynaecologists, 2012). Several case
nyms for the treatment modality. The selection of
studies showed beneficial effects of physiotherapy on
words was inspired by the European Association of
a functional level but also for patients’ quality of life
Urology’s guidelines on CPP (Engeler et al., 2014) and
(Davia and Welty, 2014; Karper, 2004; Pastore, 2013;
the Medical Subject Headings of the US National
Van Alstyne, Harrington, and Haskvitz, 2010).
Library of Medicine (2016). For the pain condition
Physiotherapy management is a systematic and cyclic
the phrases “chronic pelvic pain”, “chronic prostatitis”,
process consisting of assessment, diagnosis and prog-
“interstitial cystitis”, “painful bladder” and “bladder
nosis, intervention and reassessment. Physiotherapy
pain” were used for the search. For the treatment the
is defined as services aiming to assure maximum
phrases “physiotherapy”, “physical therapy”, “physical
movement, functional ability and quality of life,
activity”, “motor activity” and “exercise” were used.
wherein all dimensions of well-being are encom-
Based on a priori considerations, that only complemen-
passed. Services can be applied to individuals or
tary, passive manual and/or active treatments, but no
populations by or under supervision of a physical
physical or electro-therapeutic agents alone should be
therapist (World Confederation for Physical
considered in the review, the search terms were selected
Therapy, 2011). Moreover, for women with CPP,
as displayed. Treatments considered to be alternative
physiotherapy seems to empower and helps improve
medical treatments (Onopa, 1999) which are not part of
psychomotor function and working ability (Mattson,
the physiotherapy practice in all countries (Zhou, Ma,
Wikman, Dahlgren, and Mattson, 2000).
and Brogan, 2015) (e.g. acupuncture) should not be
This systematic review considers the role of phy-
part of the review. This explains the lack of keywords
sical therapy in the management of CPP. The pur-
for these interventions. Synonyms for each group were
pose is to systematically summarize and synthesize
connected with the Boolean operator OR and the two
the available evidence for physical therapy interven-
groups were connected with AND: (“chronic pelvic
tions for men and women with CPP. An emphasis
pain” OR “chronic prostatitis” OR “interstitial cystitis”
was placed on the ability of the interventions to
OR “painful bladder” OR “bladder pain”) AND
address the perceived pain. Results were clustered

(“physiotherapy” OR “physical therapy” OR “physical
activity” OR “motor activity” OR “exercise”).
In addition to the database search, the International
Clinical Trials Registry Platform of the World Health
Organization was browsed for studies recently concluded.
Hand searches in the reference lists of included papers
and relevant reviews were conducted to identify more
eligible studies.
Study selection
Studies were selected by using a two-step approach.
The first step consisted of reviewing suitable studies
based on title and abstract. After eliminating duplicates,
both researchers (SGRK) separately scanned through
titles and abstracts and evaluated the studies based on
predefined eligibility criteria: Study Type – Any quan-
titative study type of primary research was included
with the exception of case series including fewer than
10 participants. Also retrospective studies were consid-
ered. The decision was based on the method used by
Loving, Nordling, Jaszczak, and Thomsen (2012) who
showed that inclusion of randomized controlled trials
only was not feasible; Population – Females and males
over 18 years of age who were declared to have CPP by
the authors of the original studies. It was decided to
choose this pragmatic approach rather than the defini-
tion in the guidelines of the European Association of
Urology (Engeler et al., 2014) because otherwise too
many studies would have had to be excluded;
Intervention – Modalities of physical therapy could be
either active or passive treatments provided by or under
supervision of a physical therapist (World
Confederation for Physical Therapy, 2011).
Mechanical or electric devices were allowed as part of
the therapy, but not as the only therapeutic approach;
Outcome – Pain reduction as primary outcome para-
meter must be measured either using the pain section
of the National Institutes of Health Chronic Prostatitis
Symptom Index (NIH-CPSI) (Litwin et al., 1999) or the
Visual Analog Scale (VAS). The VAS was chosen
because it is a widely used and reliable instrument for
pain measurement (Hawker, Mian, Kendzerska, and
French, 2011; Lukacz et al., 2004). Moreover, from the
patients’ perspective, it seemed to cover the complexity
of chronic pain better than numeric rating scales
(Hawker et al., 2008; Hush et al., 2010); and
Publication – Studies were excluded if they were not
published in English or German. Only original work
published in journals was considered; other types of
publication like posters or congress-presentations were
not eligible.
PHYSIOTHERAPY THEORY AND PRACTICE 3
Discrepancies concerning the relevance of a study
were resolved by consensus decision. Subsequent to
reaching consensus, full texts were retrieved for all
publications which seemed to meet inclusion criteria.
The full text was also retrieved in cases where it was not
clear if the criteria were fulfilled.
In the second step of study selection, all full texts
were independently scanned for eligibility by the two
authors (SGRK) and irrelevant ones were excluded.
Exclusion had to be justified. Disagreement was
resolved by consensus decision.
Data extraction and quality assessment
The following data from the studies was processed
using Microsoft Excel Version 12.0: Study type; coun-
try, year and duration; sample size and characteristics;
description of intervention and, where possible, con-
trol; outcome measurements and its time of measure-
ment; results of pain measurement and additional
results; and dropouts.
The two researchers (SGRK) assessed the quality of
included studies. First, levels of evidence were deter-
mined. Studies were ranked according to the level of
evidence (Oxford Centre for Evidence-based Medicine,
2009) in a hierarchical order. Studies ranking high
indicate more methodological strengths in study design
(Stetler et al., 1998). Second, the Critical Review Form –
Quantitative Studies (Law et al., 1998a), a tool suitable
for different types of quantitative study designs, was
used for an in-depth critical appraisal. It is accompa-
nied by a guideline for completing the questionnaire
(Law et al., 1998b) and facilitates comparisons of dif-
ferent types of study designs due to its generic compo-
sition (Briggs, Smith, Straker, and Bragge, 2009). In its
original form, the tool did not provide a numerical
summation; however, dichotomous responses to the
items were possible. Therefore a sum score was estab-
lished from the domains study purpose, literature, sam-
ple, outcomes, intervention, results and conclusions/
clinical implications. Each question was graded with
either 1 point for “yes” or with 0 points for “no”, “not
addressed” or “N/A” resulting in a total possible score
of 14 points. In this arbitrary scoring system, higher
scores indicate higher methodological quality. No cut-
off score was established.
Data synthesis and analysis
Based on former literature searches during study conduc-
tion, the studies were expected to not only be diverse in
their application of physiotherapeutic intervention and in
4 S. G. R. KLOTZ ET AL.

their methodologies; they were also heterogeneous in the
dimensions of effect measurements. Therefore, it was
decided a priori that these circumstances would not
allow for a reasonable and convincing quantitative meta-
analysis; rather a narrative synthesis of study results
(Popay et al., 2006) was conducted. They were grouped
and summarized according to the applied physical therapy
modality and the treatment effects were described. All
data from the literature with the exception of p-values
were rounded to one decimal place. P-values were
rounded to the nearest two decimal places (exception
p < 0.001).
Results
Search results
The electronic database search returned 631 potential
studies. Three potential studies were found in the trial
registry platform, two of them were still recruiting and the
last one was already included. Hand search of the
reference lists of the included studies and the systematic
review revealed 12 possible eligible studies. After elimina-
tion of duplicates, 543 citations were screened by title and
abstracts. Figure 1 illustrates the search process using the
PRISMA flow diagram (Moher et al., 2009).
A total of 24 full text articles were retrieved and 14
records were excluded for one of two reasons. The first
group of nine studies did not fulfill eligibility criteria
for pain measurement (Anderson et al., 2015;
Anderson, Wise, Sawyer, and Chan, 2005; Anderson
et al., 2016; Clemens et al., 2000; Fitzgerald et al.,
2012; Marx et al., 2009; Marx, Cimniak, Rütz, and
Resch, 2013; Shoskes, Nickel, and Kattan, 2010; Weiss,
2001). The other group of five studies did not fulfill
eligible criteria for publication type (Berger, 2007;
Davia and Welty, 2014; Holzberg, Kellogg-Spadt,
Lukban, and Whitmore, 2001; Lukban and Whitmore,
2002; Lukban et al., 2001).
Thus, 10 remaining articles, detailing 8 different
studies, were included in the qualitative analysis. The

Records identified through Additional records identified

Identification

database searching through other sources

(n =631) (n =12)

Records after duplicates removed

(n =543)
Screening

Records screened Records excluded

(n =543) (n =519)

Full-text articles assessed Full-text articles excluded,

Eligibility

for eligibility with reasons

(n =24) (n =14)

Records included in
qualitative synthesis
Included

(n =10; reporting about 8

studies)

Figure 1. PRISMA flowchart (Moher et al., 2009) illustrating search process of the systematic review with number (n) of included
studies in each step.

study from Fitzgerald et al. (2013) is a reprint from
the article from Fitzgerald et al. (2009). The follow-
up results after 1 year from Haugstad et al. (2006b)
were published in a separate article (Haugstad et al.,
2008).
Critical appraisal
Four of the eight included studies were randomized
controlled trials (Fitzgerald et al., 2013; Giubilei et al.,
2007; Haugstad et al., 2006b; Hawk et al., 2002); how-
ever, one of them was a pilot study (Hawk et al., 2002).
Randomized controlled trials have evidence level 1b
(Oxford Centre for Evidence-based Medicine, 2009).
The remaining four studies were uncontrolled case
series or chart reviews (Anderson, Wise, Sawyer, and
Chan, 2006; Anderson et al., 2011; Cornel, van Haarst,
Browning-Groote Schaarsberg, and Geels, 2005;
Oyama et al., 2004) and were ranked evidence level 4
(Oxford Centre for Evidence-based Medicine, 2009).
Appraisal of the studies with the critical review
form resulted in a mean (SD) of 9.4 points (±3.11)
out of 14 possible points, with a range from 4 to 12
points. Table 1 shows the individual evaluations for
each study. Due to the study type, it was not possi-
ble for the case series to achieve 14 points. The
highest possible number here was 12 points, because
all participants were in the same group and contam-
ination and co-intervention among groups could not
occur. Therefore the case series did score from 4 to
10 points whereas the randomized controlled trials
received 10–12 points. Purpose was stated clearly
and intervention was described in detail in all stu-
dies. With the exception of two studies (Anderson,
Wise, Sawyer, and Chan, 2006; Anderson et al.,
2011), the outcome measures were valid and reli-
able. In those two studies a self-developed survey for
assessing symptoms, which has not been tested for
its validity and reliability, was used among other
instruments. Therefore, it was decided to rate these
items with zero points. Only two studies stated
justification for the sample sizes; one was a pre-
trial power analysis based on results from a previous
pilot study (Haugstad et al., 2006b) and the other
was pragmatic due to available resources (Hawk
et al., 2002). Another common methodological flaw
was insufficient discussion of the methodology used
in the studies. Three studies were deemed to have
appropriate conclusions and recommendations of
the used treatments in relation to the study design
(Fitzgerald et al., 2013; Haugstad et al., 2006b;
Oyama et al., 2004).
PHYSIOTHERAPY THEORY AND PRACTICE 5
Study results
After critical appraisal, studies were grouped according
to the physical therapy modality used as intervention.
Four studies used either trigger point release alone or in
combination with other techniques. Biofeedback, aero-
bic exercises, Mensendieck somatocognitive therapy,
and Thiele massage were applied each in one study.
The following paragraphs summarize the study results
of the different interventions. Detailed information
about all included studies can be found in Table 2.
Trigger point therapy
The samples of the four studies evaluating trigger point
therapy ranged from 39 (Hawk et al., 2002) to 146
participants (Anderson, Wise, Sawyer, and Chan,
2006) with a mean age between 34.2 (Hawk et al.,
2002) and 43 (Fitzgerald et al., 2013) years (range
18–80). Two studies included only male participants
(Anderson, Wise, Sawyer, and Chan, 2006; Anderson
et al., 2011), one study only females (Hawk et al., 2002)
and the last both sexes with an amount of 49% male
(Fitzgerald et al., 2013). Two of the studies were case
series examining the same intervention consisting of
trigger point therapy in combination with home exer-
cises, relaxation and breathing techniques (Anderson,
Wise, Sawyer, and Chan, 2006; Anderson et al., 2011).
The two remaining studies were randomized controlled
trials. One compared trigger point therapy, connective
tissue manipulation and home exercises with a global
therapeutic Western massage as control group
(Fitzgerald et al., 2013) and the other evaluated trigger
point therapy and chiropractic against massage and
sham chiropractic (Hawk et al., 2002). The NIH-CPSI
was used as pain measurement in two studies
(Anderson, Wise, Sawyer, and Chan, 2006; Fitzgerald
et al., 2013), the VAS was used in one study (Hawk
et al., 2002) and the remaining study used both instru-
ments (Anderson et al., 2011). All four studies mea-
sured at baseline, but only three conducted a post-
treatment measurement between 6 and 12 weeks
(Anderson, Wise, Sawyer, and Chan, 2006; Fitzgerald
et al., 2013; Hawk et al., 2002). A follow-up measure-
ment after 6 months was provided only by one study
(Anderson et al., 2011). In one of the two case series
changes in the values of the pain domain in the NIH-
CPSI (median before: 12, median after treatment: 9,
p < 0.001) and also in the VAS (median before: 4,
median after treatment: 3, p < 0.001) were significant
(Anderson et al., 2011). In the other one, the data were
presented in subgroups according to participants’ reac-
tion to the treatment. The study was able to demon-
strate significant changes in the pain domain of the
 6
S. G. R. KLOTZ ET AL.

Table 1. Overview of critical appraisal using the Critical Review Form and total score for each included study in the systematic review.
Results were Conclusions were
Was the Was relevant Was the Was Were the Were the Intervention Co- reported Were the Clinical appropriate Total
Item of the purpose background sample sample outcome outcome was intervention in terms of analysis importance Drop-outs given study score
Critical Review stated literature described in size measures measures described in Contamination was statistical method(s) was were methods and (sum
Study Form clearly? reviewed? detail? justified? reliable? valid? detail? was avoided? avoided? significance? appropriate? reported? reported? results? score)
Anderson, Wise, Sawyer, 1 0 0 0 0 0 1 N/A N/A 1 1 1 0 0 5
and Chan, 2006
Anderson et al., 2011 1 0 1 0 0 0 1 N/A N/A 0 1 0 0 0 4
Cornel, van Haarst, 1 1 1 0 1 1 1 N/A N/A 1 1 1 1 0 10
Browning-Groote
Schaarsberg, and Geels,
2005
Fitzgerald et al., 2013 1 1 1 0 1 1 1 Not addr. Not addr. 1 1 1 1 1 11
Giubilei et al., 2007 1 1 1 0 1 1 1 1 1 1 1 1 1 0 12
Haugstad et al., 2006b 1 1 1 1 1 1 1 Not addr. Not addr. 1 1 1 1 1 12
Hawk et al., 2002 1 1 1 1 1 1 1 1 1 0 0 1 1 0 11
Oyama et al., 2004 1 0 1 0 1 1 1 N/A N/A 1 1 1 1 1 10

0 = no point given for the item, 1 = one point given for the item, N/A: not applicable (items were only applicable in controlled studies, item was scored with zero points), not addr. : not addressed (no information
provided in the study, item was scored with zero points).
Table 2. Characteristics of the included studies in the systematic review including information about the authors, the sample, the inclusion and exclusion criteria, the intervention and
control groups, the results of pain and other measurements, and the dropouts.
Sample
Number of
participants,
mean age Results of pain Results of other
(range) measurement measurements Dropouts
mean Mean/median before and Mean/median before and Number of
Authors study symptom after treatment (p-Value), after treatment (p-Value), participants
type, country, duration Description of intervention Description of between group difference between group difference dropping out
time frame (range) Inclusion criteria Exclusion criteria group control group where applicable where applicable of study
Anderson, Wise, n = 146 men; Symptoms of CP/CPPS Not stated 91 men with a combination None NIH-CPSI: baseline grand PPSS: baseline grand mean Not stated, 103
Sawyer, and mean age 42 for at least 3 months of trigger point release mean 11.47, post-treatment 28.93, post-treatment grand GRA-surveys
Chan, 2006 (range (weekly for 4 weeks and grand mean 8.53 (p < 0.004) mean 19.13 (p < 0.007) * were available
case series, 18–77); biweekly for 8 weeks) and 8 * at post-
North mean sessions of paradoxical treatment
America, 01/ symptom relaxation and sinus measurement
1996–05/ duration arrhythmia breathing
2005 74 months including home exercises, 55
(range men with a modified version
3–447) consisting of trigger point
release, paradoxical
relaxation and sinus
arrhythmia breathing for a
total of 30 h in a 6-day
intensive treatment regime
Anderson et al., n = 116 men Symptoms for at least No pain, no pelvic floor 6-day intensive treatment None NIH-CPSI: baseline median PPSS: baseline median 32.5, From 200
2011 case median age 3 months, NIH IIIA/IIIB, tenderness, no TrP regime with 30 hours of 12, after 6 months median 9, after 6 months median 21, initial patients
series, North 48 (range NIH-CPSI at least 12 sensitivity, absence of pain therapy consisting of daily VAS: baseline median 4, p < 0.001 were only
America, 02/ 19–80); points, nonzero pain during trigger point testing, trigger point release, after 6 months median 3, all those included
2004–08/ median score domain only sexual dysfunction paradoxical relaxation and values p < 0.001 in the study
2009 symptom sinus arrhythmia breathing with follow-up
duration including home exercises measurement
4.8 years
(range >
1–30)
Cornel, van n = 31 men Age > 18 years, pelvic Urinary tract infections in Relaxation and contraction None NIH-CPSI: baseline mean EMG values: baseline mean Only patients
Haarst, out of a total pain or discomfort for at the past 6 months, history of pelvis floor muscles with 11.0, post-treatment mean 4.8, post-treatment mean with post-
Browning- of 33 men least 3 months, NIH-CPSI of cancer, neurological aid of biofeedback, 5.7, p < 0.001 1.7, p < 0.001 treatment
Groote starting the > 15 disorder, transurethral education and instructions measures
Schaarsberg, protocol; procedure in activities of daily living, available were
and Geels, mean age once a week, later every included in
2005 43.9 (range 2–4 weeks analysis, EMG
case series, 23–70); values only for
The mean 18 patients
Netherlands, symptom available
03/2000–03/ duration not
2004 stated
PHYSIOTHERAPY THEORY AND PRACTICE

(Continued )
7
 8

Table 2. (Continued).
Sample
Number of
participants,
S. G. R. KLOTZ ET AL.

mean age Results of pain Results of other

(range) measurement measurements Dropouts
mean Mean/median before and Mean/median before and Number of
Authors study symptom after treatment (p-Value), after treatment (p-Value), participants
type, country, duration Description of intervention Description of between group difference between group difference dropping out
time frame (range) Inclusion criteria Exclusion criteria group control group where applicable where applicable of study
Fitzgerald et al., n = 47 Age > 18 years, clinical Painful scars on lower Connective tissue Protocol of NIH-CPSI: MPT: baseline GRA: MPT: responders 13, 44 out of 47
2013 randomized diagnosis of IC/PBS or abdominal wall, positive manipulation and trigger global mean 14.2, post-treatment non-responders 10, GTM: completed
RCT, North out of a total CP/CPPS, symptoms for urine culture, previous point treatment external therapeutic mean 8.0, p < 0.0007; GTM: responders 5, non- study, results
America, of 369 at least 3 months within myofascial physiotherapy, (abdominal wall, back, Western baseline mean 12.7, post- responders 19, between based on 47
time frame screened the last 6 months, intolerance against digital buttocks and thighs) and massage, treatment mean 8.2, groups difference p < 0.03 participants
not stated persons; symptoms for less than vaginal or rectal internal (pelvic floor), 10 weeks, each p < 0.03; between groups (intention to
49% male 3 years, tenderness/pain examination, neurologic education and home treatment difference p < 0.39 treat analysis)
(n = 23); to pelvic floor palpation disorder, any concurrent exercises, 10 weeks, each 1 hour (GTM)
mean age 43 medical condition, ♀: treatment 1 hour (MPT)
(range pregnancy, symptoms only
22–76); during menses
mean
symptom
duration not
stated
Giubilei et al., n = 103 men Sedentary, NIH type III Age > 50 years, specific Aerobic exercise group Placebo/ NIH-CPSI: AEG: baseline BDI: AEG: baseline mean 97 received
2007 randomized CP concurrent or prior medical (AEG): warmup/cool down, stretching and mean 10.8, post-treatment 12.1, post-treatment mean intervention as
RCT, out of a total condition and/or isometric + strengthening motion mean 6.4, p < 0.0001; P/ 8.3, p < 0.0001; P/FlexG: assigned, 76
Italy, of 231 treatments/medications exercise, 40 minutes fast exercise group FlexG: baseline mean 11.5, baseline mean 11.2, post- were included
2002–2004 screened paced walking with 70/80% (P/FlexG): post-treatment men 8.8, treatment men 7.8, in the follow-
sedentary of predicted age-adjusted flexibility + p < 0.0001, between groups p < 0.0001, between groups up analysis
males; max heart rate; 3 times per motion difference p < 0.00009; VAS: difference p < 0.94; SAI-Y: after 18 weeks,
grand mean week for 18 weeks exercise; 3 AEG: baseline mean 5.1, AEG: baseline mean 44.0, 21 lost to post-
age 36.73*; times per week post-treatment mean 3.4, post-treatment mean 37.8, treatment
grand mean for 18 weeks p < 0.0001; P/FlexG: baseline p < 0.0001; P/FlexG: baseline
symptom mean 5.1, post-treatment mean 46.5, post-treatment
duration men 4.2, p < 0.0001, men 40.4, p < 0.0001,
5.74 months* between groups difference between groups difference
p < 0.003 p < 0.45
(Continued )
Table 2. (Continued).
Sample
Number of
participants,
mean age Results of pain Results of other
(range) measurement measurements Dropouts
mean Mean/median before and Mean/median before and Number of
Authors study symptom after treatment (p-Value), after treatment (p-Value), participants
type, country, duration Description of intervention Description of between group difference between group difference dropping out
time frame (range) Inclusion criteria Exclusion criteria group control group where applicable where applicable of study
Haugstad et al., n = 40 Not stated Somatic diseases such as Standard gynecological STGT alone VAS: STGT+MSCT: baseline Standardized Mensendieck 3 lost to
2006b women; cancer, disk herniation, treatment (STGT): hormonal mean 5.60, post-treatment Test: STGT+MSCT: baseline follow-up
RCT, Norway, grand mean trapped ovary syndrome; treatment, analgetics, mean 2.89, follow-up mean mean 17.01, post-treatment
time frame age 33.29*; psychological disorders such dietary and/or sexologic 2.00, p < 0.001; STGT: mean 22.19, follow-up mean
not stated grand mean as drug dependency, advice (2 sessions) + baseline mean 6.68, post- 24.41,; STGT: baseline mean
symptom anorexia, bipolar disorder; Mensendieck treatment mean 6.16, 18.56, post-treatment mean
duration lumbar nerve root affection; somatocognitive therapy follow-up mean 5.95, 18.21, follow-up mean
6.325 years* pelvic instability (MSCT): movement patterns p < 0.077 18.15; between groups
aimed at body awareness, differences all p < 0.01
balanced posture and
controlled movement,
awareness of tension and
relaxation, and functional
respiration (10 sessions each
1 hour)
Hawk et al., n = 39 Females between 18and Pregnancy, menopause, Chiropractic (lumbar spine Sham VAS: chiropractic: baseline PDI: chiropractic: baseline Three lost to
2002 women 45 years, CPP diagnosis surgery past 6 months, flexion-distraction) + trigger chiropractic grand median 3.87, post- grand median 16, post- follow-up
RCT, North enrolled out of at least 6 months, pathology, contraindication point therapy in low-back procedure and treatment grand median 4.1, treatment grand median
America, of 153 naive to chiropractic manipulation, no and pelvic area, 14 visits light massage/ 12-week follow-up grand 10.33, 12-week follow-up
1999–2000 eligible manipulation musculoskeletal each 15 minutes effleurage, 14 median 2.9; placebo: grand median 3.5; placebo:
participants dysfunction, litigation for a visits each baseline grand median 1.83, baseline grand median
(355 health-related claim, 15 minutes post-treatment grand 18.33, post-treatment grand
screened); treatment for any condition median 0.56, 12-week median 9.66, 12-week
mean age follow-up grand median follow-up grand median
43.2; −0.04 * 2.16; MPQ: chiropractic:
mean baseline grand median 19,
symptom post-treatment grand
duration median 11.17; placebo:
8.4 years baseline grand median
(range 0.5– 22.83, post-treatment grand
31) median 18.83 *
(Continued )
PHYSIOTHERAPY THEORY AND PRACTICE
9
 10
S. G. R. KLOTZ ET AL.

Table 2. (Continued).
Sample
Number of
participants,
mean age Results of pain Results of other
(range) measurement measurements Dropouts
mean Mean/median before and Mean/median before and Number of
Authors study symptom after treatment (p-Value), after treatment (p-Value), participants
type, country, duration Description of intervention Description of between group difference between group difference dropping out
time frame (range) Inclusion criteria Exclusion criteria group control group where applicable where applicable of study
Oyama et al., n = 21 Age > 18 years, stable No previous sexual activity, 10 intravaginal massages None VAS: baseline mean 5.4, ICSI: baseline mean 8.9, 8 lost to
2004 women; treatment regimen at sacral neuroprosthetic, using Thiele technique, two post-treatment 3.5 post-treatment 6.9 follow-up
case series, mean age 42 least 1 month before external pelvic instability massages per week, each (p < 0.005), follow-up 2.6 (p < 0.015), follow-up 5.1
North (range study about 5 minutes (p < 0.005) (p < 0.02); ICPI: baseline
America, 21–64); mean 8.2, post-treatment
time frame mean 6.3 (p < 0.039), follow-up 6.0
not stated symptom (p < 0.049); SF-12: baseline
duration not grand mean 87.9, post-
stated (range treatment grand mean 96.1
5–14 years) (p < 0.049), follow-up grand
mean 94.1 (p < 0.155) *
AEG: aerobic exercise group; BDI: beck depression inventory; CP: chronic prostatitis; CP/CPPS: chronic prostatitis/chronic pelvic pain syndrome; CPP: chronic prostatitis; EMG: electromyography, GRA: global rating
assessment; GTM: global therapeutic massage; IC/PBS: interstitial cystitis/painful bladder syndrome; ICPI: O’Leary-Sant IC Problem Index; ICSI: O’Leary-Sant IC Symptom Index; MPQ: McGill Pain Questionnaire; MPT:
myofascial trigger point treatment; MSCT: Mensendieck somatocognitive therapy; NIH: National Institutes of Health, NIH-CPSI: National Institutes of Health Chronic Prostatitis Symptom Index; P/FlexG: placebo/
stretching and motion exercise group; PDI: Pain Disability Index; PPSS: pelvic pain symptom survey, RCT: randomized controlled trial; SAI-Y: state anxiety inventory-Y; SF-12: short form health survey; STGT: standard
gynecological treatment; TrP: trigger point; VAS: Visual Analog Scale, * indicates calculation of grand mean and grand median done by review authors

NIH-CPSI only for the subgroup of markedly and
moderately improved participants (mean before: 11.3
and 12.6 respectively, mean after treatment: 7.5 and 8.9
respectively, both p < 0.001), not for the slightly
improved ones (mean before: 10.5, mean after treat-
ment: 9.2, p = 1.0) (Anderson, Wise, Sawyer, and Chan,
2006). In the first randomized controlled trial, both the
trigger point therapy and the global Western massage
improved significantly (mean before: 14.2, mean after
treatment: 8.0, p < 0.001 and mean before: 12.7, mean
after treatment: 8.2, p < 0.03 respectively) in pain mea-
surement before and after treatment (Fitzgerald et al.,
2013). However, no significant difference (p < 0.39)
between groups could be established. Only the self-
reported global rating assessment was able to demon-
strate a significant benefit (n = 13 responder in the
intervention group, n = 5 responder in the control
group, p < 0.03) in favor of the intervention group. In
the second randomized controlled trial, no overall
effect sizes and p-values were calculated due to incon-
sistent findings across their three study sites (Hawk
et al., 2002). The grand medians, calculated by the
review authors, showed decreasing values in the inter-
vention and the control group for the pain measure-
ment with the VAS, but also for the additional pain
measurement using the Pain Disability Index and the
McGill Pain Questionnaire. Dropout rates were low
with up to three participants dropping out (Anderson
et al., 2011; Fitzgerald et al., 2013; Hawk et al., 2002);
however, one study did not report dropout rates
(Anderson, Wise, Sawyer, and Chan, 2006).
Biofeedback
A total of 31 men whose mean age was 43.9 years
(range 23–70) were included in the biofeedback study
(Cornel, van Haarst, Browning-Groote Schaarsberg,
and Geels, 2005). They used biofeedback with a rectal
electromyography probe for relaxation and contrac-
tion of the pelvic floor in supine position but also in
activities of daily living. Pain was measured using the
pain domain of the NIH-CPSI at baseline and after
treatment. Pain scores decreased from a mean value
of 11.0 to 5.7 (p < 0.001). Additionally, the electro-
myography values decreased from a mean value of
4.8 to 1.7 (p < 0.001). Only participants with com-
plete data were included in the analysis (Cornel, van
Haarst, Browning-Groote Schaarsberg, and Geels,
2005).
Aerobic exercise
In a randomized controlled trial, aerobic exercises con-
sisting of isometric and strengthening exercises combined
with 40 minutes of fast paced walking were combined
PHYSIOTHERAPY THEORY AND PRACTICE 11
with stretching and motion exercises as a placebo in a
group of 103 males with a grand mean of 36.7 years
(Giubilei et al., 2007). Both, the NIH-CPSI pain domain
and the VAS were used for pain measurement at baseline,
after 6 weeks and post-treatment after 18 weeks. In the
treatment group and in the control group both pain scales
decreased significantly from baseline to post-treatment
(both p < 0.001); however, the improvements were higher
in the treatment group. Thus, significant group differ-
ences in both pain scales could be found in favor of the
treatment group (NIH-CPSI p < 0.001, VAS p < 0.01). For
the parameters “anxiety” and “depression”, values
improved significantly (p < 0.001) in both groups, but
no significant group difference could be identified
(p < 0.45 and p < 0.94, respectively). The study had a
loss to post-treatment measurement of 21 participants
(Giubilei et al., 2007).
Mensendieck somatocognitive therapy
Mensendieck therapy is a body-oriented therapy
developing new body awareness, posture and move-
ment (Mensendieck, 1954). The effect of this ther-
apy approach combined with standard gynecological
treatment compared to standard gynecological treat-
ment alone was examined in a randomized con-
trolled trial (Haugstad et al., 2006b, 2008). A total
of 40 women with a grand mean of 33.3 years took
part in the study. Pain was measured using the VAS
at baseline, post-treatment after 3 months and fol-
low-up at 12 months. Pain decreased significantly
(p < 0.001) for the intervention group, but not for
the control group (p < 0.08). In addition to the pain
measurement, the Standardized Mensendieck Test
was used, which showed a significant group differ-
ence in all subdomains favoring the treatment group
(p < 0.01). Only three participants were lost to
follow-up (Haugstad et al., 2006b, 2008).
Thiele massage
Thiele massage is a specific technique of massaging
the fibers of the pelvic floor in the long direction
with first light and then increasingly more pressure
in subsequent sessions (Thiele, 1937). As it was con-
sidered to be a different treatment modality than
trigger point therapy, the effect of Thiele massage
was examined separately. It was evaluated in a case
series with 21 women with a mean age of 42 years
(range 21–64) (Oyama et al., 2004). Participants
received 10 units of intravaginal Thiele massage.
Pain levels were assessed using VAS at baseline,
post-treatment and follow-up at 4.5 months. The
values decreased significant (p < 0.01) from a base-
line mean of 5.4 to follow-up mean of 2.6.
12 S. G. R. KLOTZ ET AL.
Furthermore, changes in the O’Leary-Sant Interstitial
Cystitis Problem Index and the O’Leary-Sant
Interstitial Cystitis Symptom Index were also signifi-
cant (p < 0.02 and p < 0.05, respectively) but nor for
12-Item Short Form Health Survey (p < 0.16). Of the
21 women, 8 were lost to follow-up (Oyama et al.,
2004).
Discussion
Summary of evidence
Physiotherapy for patients with CPP is advocated in sev-
eral guidelines (Engeler et al., 2014; Jarrell et al., 2005;
Royal College of Obstetricians and Gynaecologists, 2012)
and also incorporated in the UPOINT classification
(Shoskes, Nickel, Rackley, and Pontari, 2009).
Nevertheless, rigorous evidence of the effect of phy-
siotherapy in CPP is still lacking. The review has synthe-
sized the available evidence concerning physical therapy
for both male and female patients with CPP focusing on
its capacity for pain reduction. A total of 8 studies pre-
sented in 10 publications were examined. Half of the
studies were uncontrolled case series with evidence level
4, the other half were randomized controlled trials with
evidence level 1b (Oxford Centre for Evidence-based
Medicine, 2009).
Trigger point therapy
There is some evidence for the valuable effects of trig-
ger point therapy gained from two randomized con-
trolled trials (Fitzgerald et al., 2013; Hawk et al., 2002)
and two uncontrolled case series (Anderson, Wise,
Sawyer, and Chan, 2006; Anderson et al., 2011).
However, one of the randomized controlled trials was
a pilot study with inconsistent findings and no estima-
tion of overall effect (Hawk et al., 2002). The authors
did not design the study for effect testing, but rather as
a means for testing the feasibility of a combination of
chiropractic and trigger point therapy. Therefore,
results of this study should be related to the context
of pilot testing. In the other randomized controlled
trial, treatment regimes were used which the authors
deemed to have no specific effect in patients with CPP;
however, both intervention and control group showed
significant improvements in pain levels measured with
the NIH-CPSI comparing baseline with post-treatment
indicating at least some effect on those patients
(Fitzgerald et al., 2013). Moreover, the original self-
reported global response assessment has seven cate-
gories, but these ratings were condensed into a two
class system by the study authors. Participants stating
that the treatment showed slight improvement were
classified as non-responders. Changing the converting
system might have produced different results.
Additionally, an effective physical therapy may be
attributed to other factors, such as the patient–therapist
relationship, rather than solely to the intervention (Hall
et al., 2010; Paterson and Dieppe, 2005). This consid-
eration could be a possible explanation for the signifi-
cant changes also evident in the control groups.
Apart from the lack of control groups to set their
results in perspective, the two case series (Anderson,
Wise, Sawyer, and Chan, 2006; Anderson et al., 2011)
achieved only 5 and 6 of 12 possible points respectively
on the critical appraisal tool, indicating a significant
number of methodological flaws, which may have
affected the conclusions drawn from these studies.
The older case series (Anderson, Wise, Sawyer, and
Chan, 2006) used different treatment regimes: 55 of
the 91 men received an intensive 6-day treatment pro-
tocol, whereas the rest were treated with a 3-month
program, complicating general statements about results
of the study. Rather than presenting raw data, the
patients were grouped according to improvement on
the pain domain of the NIH-CPSI in the result section,
making calculation of grand means necessary. The
younger case series (Anderson et al., 2011) only
included participants in their retrospective case series
for whom all data were available, excluding 84 patients
without providing information about the reasons for
their exclusion. It might be that these patients decided
to quit treatment because of an aspect of the treatment
itself, therefore affecting outcome results.
Effectiveness of other therapies
For all other examined treatment modalities, only little
evidence in form of one study for each treatment is
available. Two randomized controlled trials showed at
least some effect of Mensendieck somatocognitive ther-
apy (Haugstad et al., 2006b) and of aerobic exercises
(Giubilei et al., 2007) respectively. Nevertheless, limita-
tions of both studies must be considered. In the
Mensendieck therapy trial (Haugstad et al., 2006b),
the effect of treatment was measured with the VAS
and the Standardized Mensendieck Test (Haugstad
et al., 2006a). This test was designed specially to mea-
sure the components that were targeted by the
Mensendieck somatocognitive therapy. Therefore, it is
not surprising that only the intervention group
improved significantly in these scores whereas the con-
trols changed only slightly. Nevertheless, it was able to
confirm the positive findings in the intervention group
with the VAS as pain measurement. In the aerobic

exercises study (Giubilei et al., 2007), patients aged over
50 years were excluded in order to delimitate sport-
related side effects, which limits transferability to older
patients. Additionally, the authors reported that their
dropouts were older, which may be another sign that
active treatment regimes might be more difficult to
realize in older patients.
Biofeedback and Thiele Massage were tested only in
small, uncontrolled case series (Cornel, van Haarst,
Browning-Groote Schaarsberg, and Geels, 2005;
Oyama et al., 2004). Although they both reported sig-
nificant improvements in pain measurements, it was
not possible to set their results in relation to the effects
of other interventions. The sample size of the biofeed-
back case series (Oyama et al., 2004) was small to begin
with and the high loss to follow-up (38%) introduced a
potential risk for errors. While all 21 women completed
the intervention, only 13 participants were available for
follow-up measurements, which might have biased the
results for long-term effect. Both included either only
men or only women, thus limiting the transferability of
the respective therapy to the opposite sex.
An issue, which arose for all physical therapy treat-
ment modalities and their evaluation of effectiveness,
was the difference between statistically significant and
clinically meaningful changes in pain (Bhardwaj et al.,
2004). Although nearly all of the included studies
showed a statistically significant decrease in the pain
measurement, statements about the clinical importance
of these changes are difficult to make as there is only
insufficient literature about established cut-off points
for both instruments in both female and male patients
with CPP. For the pain domain of the NIH-CPSI, a
distinction between mild, moderate and severe pain
exists only for male patients (Wagenlehner et al.,
2013) and cut-off scores for response to treatment are
available only for the NIH-CPSI total score (Propert
et al., 2006). The classification of mild, moderate and
severe pain with the VAS seems to be doubtful at all
(Boonstra, Schiphorst Preuper, Balk, and Stewart,
2014). Hence, it remains unclear whether these statisti-
cally significant changes in the patients with CPP repre-
sent actually clinically important ones.
Comparison to literature
Compared to the single existing systematic review in
this field from Loving, Nordling, Jaszczak, and
Thomsen (2012), the review at hand provides a more
recent and more holistic overview of the effectiveness
of physiotherapy in patients with CPP as it includes
both men and women. Both genders are affected by this
medical condition and, in our opinion, the exclusion of
PHYSIOTHERAPY THEORY AND PRACTICE 13
one cannot be justified. Loving, Nordling, Jaszczak, and
Thomsen (2012) included 10 studies in 11 articles in
their systematic review. They found some evidence for
physiotherapy in context of multidisciplinary interven-
tion and for Mensendieck somatocognitive therapy.
However, due to their limitation to female participants,
they missed two of the studies about trigger point
therapy (Anderson, Wise, Sawyer, and Chan, 2006;
Anderson et al., 2011) included in this review.
Moreover, evidence for aerobic exercises can be found
only in a randomized controlled trial with males
(Giubilei et al., 2007). Nevertheless, they noted a lack
of sufficient evidence for physiotherapy in patients with
CPP and an urgent need for good quality studies, which
can be confirmed in this review.
Strengths and limitations of the review
Some limitations of this systematic review have to be
mentioned. First, there is the possibility that relevant
studies might have been overlooked as a result of the
search strategy. To reduce this opportunity, different
databases with various emphases were used and addi-
tional hand searches were performed. Predefined inclu-
sion and exclusion criteria determined the chosen studies;
other criteria might have led to other results, for example
extending the included interventions for other physical
therapy modalities like electrotherapy as the sole inter-
vention or interventions which are not part of the phy-
siotherapy practice in every country like acupuncture
(Zhou, Ma, and Brogan, 2015). Furthermore, for evalua-
tion of the primary outcome criteria studies with other
instruments than the NIH-CPSI or the VAS could have
been included. Relaxation of the inclusion criteria with
regard to the applied pain measurements and thereby
inclusion of less standardized might have captured a few
more studies. Nevertheless, exclusion of studies happened
in many cases due to lack of pain measurement or lack of
reporting pain domain scores, an issue which would not
be solved by broadening the allowed pain scales. In addi-
tion, a strict methodology was applied in this review
including usage of valid and reliable instruments and
application of a non-validated instrument was deemed
to minimize the seriousness of this methodology.
Second, pain reduction was defined as primary out-
come measure for this review. It could be discussed
whether improvement for patients with CPP is depen-
dent only on pain reduction, rather than on other
effects such as improvement in physical activity or
quality of life. Nevertheless, in order to make state-
ments concerning effectiveness in this review, pain
reduction was operationalized as a target parameter.
14 S. G. R. KLOTZ ET AL.
Third, due to the diversity of studies included, it was
decided to abstain from performing a meta-analysis.
On the other hand, the review has some major
strengths. To our knowledge, this is the first review look-
ing at physical therapy for CPP in both male and female
patients. It uses a rigorous methodological approach with
two independent experts performing the database
searches, the selection of studies, and the critical appraisal.
During this process no substantial disagreements
occurred.
Conclusions
Physical therapy methods are widely used among patients
with CPP and are regarded as particularly helpful (O’Hare
et al., 2013), indicating a high acceptance for this
approach. It can influence the musculoskeletal findings
in patients with CPP (Chaitow, 2007). Moreover, it has
the ability to empower persons with CPP, emphasizes the
patient’s competence and encourages them to set their
own personal goals for therapy (Baranowski et al., 2013;
Mattson, Wikman, Dahlgren, and Mattson, 2000; Potts,
2008). However, application of physical therapy in
patients with CPP is still empirical (Nickel et al., 2007).
In addition, physiotherapy should not be the only treat-
ment in those patients rather a multidisciplinary treat-
ment regime with accompanying psychosocial therapy
approaches should be used (Engeler et al., 2014;
Shoskes, Nickel, and Kattan, 2010).
Based on the findings in our research, trigger point
therapy shows some promising approaches. It is also
incorporated in the guidelines for CPP of the European
Association of Urology (Engeler et al., 2014). In the
absence of conclusive evidence in favor of other therapies,
trigger point therapy might be useful in patients with CPP.
However, there is a lack of high-level evidence stu-
dies using control groups and rigorous study protocols.
According to our review, the current available evidence
has several underlying methodological flaws and could
provide only limited Support for physiotherapy as
treatment option for CPP. There is an urgent need for
randomized controlled clinical trials to identify the
most effective physical therapy treatment modality.
Future studies may consider relevant outcomes and
clinically important changes in the outcome parameter
as well as sufficient follow-up measurements in order to
strengthen the evidence. Rather than only focusing on
symptom level, other aspects of treatment success such
as quality of life and empowerment should also be
taken into account. Moreover, in accordance with the
recommendations for multidisciplinary management of
CPP (Engeler et al., 2014; Shoskes, Nickel, and Kattan,
2010), future studies should consider integration of
physical and psychosocial therapy modalities in one
treatment regime.
Declaration of Interest
The authors report no declarations of interest.
Funding
The authors would like to acknowledge the PRANA
Foundation in the Stifterverbandfür die Deutsche
Wissenschafte.V., which founded the Interdisciplinary
Research Platform “Chronic Pelvic Pain Syndrome” at the
University Medical Centre Hamburg-Eppendorf. The review
is a result of this interdisciplinary research project. The
PRANA Foundation had no involvement in any step of the
review process.
Notes on contributor
Susanne G. R. Klotz is a physiotherapist and health scientist
and is currently studying in a PhD programme. Mila Schön is
a physiotherapist working in the field of women’s health.
Gesche Ketels is a physiotherapist and health economist and
is working in the leadership team of the Department of
Physiotherapy. Bernd Löwe is the dean of the Department
of Psychosomatic Medicine and Psychotherapy and a medical
specialist in psychosomatic medicine and psychotherapy.
Christian A. Brünahl is a senior physician at the
Department of Psychosomatic Medicine and Psychotherapy
and a medical specialist in psychosomatic medicine and
psychotherapy.
ORCID
Susanne G. R. Klotz http://orcid.org/0000-0002-9886-9032
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