Physical Therapy for Chronic Pelvic Pain

Physical Therapy for Chronic Pelvic Pain

Hannah Manik, SPT

BACKGROUND:
This capstone project was developed as a contribution to UNC’s future Women’s Health Physical Therapy Residency curriculum. The topic allowed me to merge two areas of physical therapy practice that I am passionate about: pelvic health and chronic pain management.

As I pursued my undergraduate degree in sociology, I gradually acquired an interest in the psychological, behavioral, and environmental influences of pain and disability. Throughout physical therapy school and my clinical experiences, this evolved into a passion for chronic pain management and the complexity of the experience of pain. I grew particularly curious about the influence of biopsychosocial factors on an individual’s pain experience and physical therapy outcomes. Once I was introduced to pelvic health physical therapy, I began to draw connections between the specialty and these interests.

Pelvic health conditions often impact many aspects of one’s physical, psychological, social, and emotional functioning.1 Furthermore, pelvic pain and bowel, bladder, & sexual dysfunction can deprive patients of their basic physiological needs, sense of belonging, and self-esteem.2 After learning how many people with these conditions suffer in silence due to misdiagnosis, underdiagnoses, and/or a lack of specialized providers, I became determined to help impact this underserved population.3 This project gave me the opportunity to contribute to the growing field of pelvic health rehabilitation and to better-prepare for my final clinical rotation in outpatient pelvic health.

PROJECT OVERVIEW & PURPOSE:
Chronic pelvic pain (CPP) describes pain in the pelvic region that lasts for six months or longer.4 CPP affects an estimated 15% of women between 18-50 years old, costs the healthcare system upwards of $800 million each year, and contributes to lost workplace productivity.5 In 2006, the WHO declared that CPP is “a neglected reproductive health morbidity” due to a lack of high-quality literature and access to treatment.6 Since then, a growing body of evidence has advanced and expanded treatment options for those suffering from CPP and physical therapists have become an important part of their multi-disciplinary team.2,4,5 In order to mitigate CPP’s economic burden and prevalence & effectively manage patients, it is critical that pelvic health PT’s are knowledgeable about an updated evidence-base for CPP diagnosis and treatment.

This learning module was designed to advance the residents’ skills in evaluating and managing CPP conditions in female patients. CPP is an umbrella term for lots of diagnoses (i.e. vulvodynia, pudendal neuralgia, etc.), though often no specific etiology can be identified.5 Recognizing that each pelvic pain diagnoses could be an entire module unto itself, this learning module emphasizes the application of general chronic pain management concepts in the context of CPP clinical case studies.

STATEMENT OF NEED:
UNC’s faculty of the Division of Physical Therapy is developing a Women’s Health Physical Therapy Residency. The curriculum, which is still under development, will consist of a series of online learning modules that cover a variety of women’s health topics. My two-week module on chronic pelvic pain will contribute to this curriculum.

Through my conversations with many physical therapists and Dr. Debby Givens, my capstone advisor, it became apparent that most physical therapy programs only briefly cover the complexities of chronic pain management, if at all. In order to address common knowledge gaps, I narrowed the focus of this module and my products the general pathophysiology, evaluation, and management of chronic pain conditions in the context of pelvic health cases and the biopsychosocial model of pain.

PRODUCTS:

• The syllabus and schedule provide an outline of weekly topics, assignments, and recommended literature and clinical resources.
• The 25-minute VoiceThread on Chronic Pelvic Pain follows a 43-year-old woman who presents to PT with interstitial cystitis (IC), dyspareunia, and low back pain (LBP) that significantly impact her emotional well-being and functional independence. Her case is used to demonstrate the pathophysiology of IC and other CPP diagnoses to optimize PT’s ability to effectively evaluate and manage these conditions.
• This case-based learning activity gives residents the opportunity to rehearse the course content and apply clinical decision-making prior to use in clinical practice.
• Lastly, I created a short chronic pain terms list & common pelvic pain conditions document that is intended to be used as a reference as learners’ come across unfamiliar terminology throughout the module.

EVALUATION:
My committee members consistently provided me with valuable evaluative feedback throughout the semester, which was critical to the success of this project.

Unfortunately, I will not receive direct feedback from residents using this module until UNC finalizes and begins the Women’s Health Physical Therapy Residency curriculum in the next year or two. To adjust for this delay, I created a brief, anonymous feedback survey regarding how effective and engaging any viewer’s found my voice presentation.

SELF-ASSESSMENT:
Initially, I felt that this project was out of my comfort zone in that it required breadth and depth of expertise in chronic pelvic pain that was beyond my knowledge or experience. In actuality, these challenges helped me develop strong relationships with many knowledgeable physical therapists, develop a greater appreciation and knowledge for pelvic health rehabilitation, and increased my confidence in my ability to educate others in my profession. A lot of time, effort, and passion went into creating these final products from myself and my committee members, who pointed me in the right direction and helped me narrow my focus for a very broad topic. While I wish my presentation was more succinct and that my module could cover more conditions, I am happy with the overall products. Through this experience, I gained a new appreciation for mentorship and my ability to educate myself and others.

ACKNOWLEDGEMENTS:
I’d like to thank Dr. Debby Givens, my capstone advisor, for providing me valuable feedback & her expertise in chronic pain, trusting me with this project, and allowing me the opportunity to explore and merge two areas of long-term personal interest and passion. Special thanks to my committee members, Autumn Bonner, DPT and Abbie DeWitt, DPT, for their ongoing support, contributions, and feedback throughout the creation of this project. Their passion for and expertise in pelvic health & chronic pain rehabilitation were indispensable to the quality of this learning module. It has been a pleasure to work with such a knowledgeable, enthusiastic, and generous committee.

REFERENCES:

1. Fenton BW, Grey SF, Tossone K, McCarroll M, Von Gruenigen VE. Classifying Patients with Chronic Pelvic Pain into Levels of Biopsychosocial Dysfunction Using Latent Class Modeling of Patient Reported Outcome Measures. Pain Res Treat 2015;2015:940675. doi:10.1155/2015/940675.
2. Chronic Pelvic Pain (2014). Retrieved February 26, 2019 from http://www.pelvicpain.org/docs/patients/Patient-Education-Brochure.aspx
3. Pelvic Pain Among Women 18-44 Prevalent, Often Untreated. Available at: https://www.apta.org/PTinMotion/News/2015/8/14/PelvicPain/. Accessed April 10, 2019.
4. Patient education: Chronic pelvic pain in women (Beyond the Basics) – UpToDate. Available at: https://www.uptodate.com/contents/chronic-pelvic-pain-in-women-beyond-the-basics. Accessed January 25, 2019.
5. Stein SL. Chronic pelvic pain. Gastroenterol Clin North Am 2013;42(4):785-800. doi:10.1016/j.gtc.2013.08.005.
6. Latthe P, Latthe M, Say L, Gülmezoglu M, Khan KS. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health 2006;6:177. doi:10.1186/1471-2458-6-177.