The Use of Physical Therapy in Treatment for Endometriosis

“I have had severe endometriosis for many years and have had several surgeries. Also started having another type of pain, which was very severe. It felt to me like bladder spasms, and I was having frequency urination of every 20 minutes all day long. I finally went to an excellent urologist who was able to feel my pelvic floor muscles through an internal exam and found that my pelvic floor muscles were in spasm (or hypertonic). He prescribed Ativan for a very short term and physical therapy. . . “

There were many days I trudged into NYC feeling awful to get to my physical therapy twice a week in the winter, but I kept going because I was desperate for some relief. It was really my lifeline and I came to look forward to it. It seems that after years of pain in my abdomen I had clenched my abdominal and pelvic floor muscles so much that they were in a constant holding or tightening pattern and they had lost their normal function.? Dale E, Endometriosis Association member, New Jersey (03/09/2006)

Endometriosis is a condition known to many women of all ages. It has been estimated that about 5-15% of women of reproductive age are affected by the disease.¹

Endometriosis occurs when tissue similar to the lining of the uterus is found elsewhere in the body, including on the surface of the reproductive organs such as the ovaries, fallopian tubes, cul-de-sac and rectal-vaginal septum.²

Scar tissue and adhesions can be formed due to endometriosis. Adhesions are fibrous bands of scar tissue that form between surfaces within the body. Once this occurs, a change in the internal anatomy can be noted and may result with organs coming together (?frozen pelvis?).³ For most of these women, pain is a consequence resulting in chronic pelvic pain (CPP). CPP is diagnosed when patients have pain in the pelvic region lasting for 6 months or more.⁴

?Levator ani syndrome, or pelvic floor pain syndrome, is a fairly common cause or association of chronic pelvic pain in women. It is uncommon for it to also be associated with endometriosis. In fact, it very commonly occurs as a secondary effect of any disorder or disease that causes recurrent or chronic pelvic pain. Additionally, discordant urination and defecation can also be symptoms of pelvic floor dysfunction.? Fred Howard MS, MD (01/2001) Endometriosis Association Advisor, Professor of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, New York

Endometriosis can result in what is known as pelvic floor dysfunction (PFD). The pelvic floor consists of muscles, connective tissue and supporting ligaments, which form a sling from the pubic bone to the tailbone. The pelvic floor structures support the abdominal and pelvic organs as well as assisting with sphincter and sexual functions. Pelvic floor dysfunction (PFD) refers to problems that occur when these muscles are weak, in spasm or too tight. Millions of Americans (women, men and children) are suffering from pelvic floor disorders, which commonly affect the urinary, genital and/or colorectal system. Most of these people are unaware of the pelvic floor dysfunction diagnosis and therefore uncertain if they have the disorder.

?It has been my experience that this condition (PFD) is certainly more common in patients with chronic pelvic pain for any number of reasons to include endometriosis. The pelvic floor muscles consist of the levator ani, piriformis and obturator internus. It is crucial that those of us dealing with these patients have knowledge of how to diagnose and treat these conditions.

Physical therapy, muscle trigger point injections, patient stretching exercises and various other treatments have been successful. The underlying mechanisms for these nerve abnormalities can be explained on the basis of the viscerosomatic reflexes at the spinal cord level.? Paul Perry, MD, Chairman of the Board of the International Pelvic Pain Society Birmingham, Alabama (01/2001)

The relationship of the pelvic floor and the abdominal muscles plays significant role in people with PFD. A normal co-contraction of the pelvic floor and abdominal muscles occurs in activities such as coughing, sneezing or laughing. It has been stated that this co-contraction is normally good, unless there are active trigger points and irritation to the abdominal/pelvic musculature (including scarring, injury, inflammation).⁵ This relationship between pelvic floor and abdominal muscles can be of great significance in women with endometriosis. Many of the women undergo laparoscopic surgeries and lysis of adhesions leaving them with painful scars and inflamed abdominal muscles.

The symptoms and signs associated with endometriosis can vary due to location of adhesions and endometrial implants. For example, pain with defecation may be due to adhesions in the large intestines.⁶ Similarly, pain associated with menstruation or with sexual intercourse (dyspareunia) may be due to adhesions of the abdominal and pelvic floor structures. Other symptoms may include painful urination, infertility, fatigue and gastrointestinal disturbances (constipation, diarrhea, bloating and nausea).² Women may also note that they have back pain with their periods or back, hip or pelvic pain with intercourse.

The best way to approach the management of endometriosis is through a multidisciplinary approach. This may include: general practitioners, gynecologists, surgeons (from a number of disciplines), reproductive endocrinologists, immunologists, nutritionists/dieticians, nurses, mental health practitioners, pain management/specialists and physical therapists. (Endometriosis Association?s latest book offers a multidisciplinary perspective on managing endometriosis and related health problems. ?Endometriosis: The Complete Reference for Taking Charge of Your Health.?)

?Yes, I very often send my patients with endometriosis and pelvic pain to a physical therapist. I have found that this helps with pain relief and gives the patient a sense of control over their symptoms.? Dr. Claire Templeman (02/18/2006) University of Southern California, Los Angeles, CA

Physical therapists are educated in the musculoskeletal system, and if educated about PFD, can identify if the pelvic and/or abdominal structures are involved, such as during endometriosis. PFD is more difficult to diagnose than other musculoskeletal dysfunctions because the pelvic floor muscles are ?out of sight? compared to other muscles since they surround the urethra, rectum, vagina and reproductive organs.

A typical therapy evaluation should focus on the abdominal and pelvic areas, but not ignore the rest of the body. The posture and alignment of the patient is first observed. The therapist may also test for any sacroiliac joint dysfunction. The therapist will also assess any limitations through range of motion of the upper and lower extremities and their strength. Neural (nerve) tension tests are tests of provocation that are performed passively in order to stress the area of neural (nerve) tissue and note for any irritation and discomfort along the neural tissue pathway.

For example, the Sciatic nerve can be tested with the patient lying on their back, test leg in a position perpendicular to the treatment table and then brought across the body (into adduction). A test is considered positive if there are signs of pain due to increased resistance of the tissues and reproduction of symptoms.⁷ The therapist will use a ?hands-on? technique to palpate the tissues and musculature. This usually consists of both an external (abdominal, gluteal/buttock, back muscles, etc?) and internal pelvic examination (transvaginal or transrectal).

Most patients may feel uncomfortable about this type of therapy and want to know why this is necessary. The answer: this is the best way to palpate and evaluate the pelvic floor muscles and observe any restrictions in the tissues and structures such as the bladder, ovaries and uterus. Palpation is crucial in noting the location of trigger points and decreased connective tissue mobility. Finally, biofeedback can be used in order to evaluate the pelvic floor muscle strength and ability to relax. Biofeedback allows the patient to see the muscle activity in the pelvic floor through a sensor and is used to help teach the patient how to relax or activate these muscles on their own.

Physical therapy helps most or all of these symptoms previously described through techniques such as myofascial trigger point release, deep tissue, scar tissue and connective tissue manipulation of the internal and external pelvic, abdominal, hip and back structures. Women with endometriosis commonly have trigger points in the abdominal wall as well as the pelvic floor, back and gluteal (buttock) muscles. According to Travell and Simons, a Myofascial Trigger Point (MTrP) is defined as a ?hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band.?⁸ When pressure is applied onto a MTrP, referred pain and/or tenderness may occur. Trigger points found in the abdominal wall are probably a result of dysmenorrhea⁹, chronic pain and/or surgery.

Connective tissue manipulation is used for improving circulation to areas with decreased blood flow and pelvic congestion. This also allows for better mobility of the surrounding structures.¹⁰ Connective tissue is mobilized by techniques such as skin rolling. The therapist will note any changes to the skin texture, color, temperature and elasticity. Areas of restrictions will be noted to feel sharp or bruised as opposed to a ?scratching sensation? in normal connective tissue.⁵

?I feel that connective tissue mobilization in the referral areas of the pelvis (Sir Henry Head) and intra-vaginal soft tissue mobilization work best for the patients I treat with endometriosis. I probably see a 75% success rate with these patients who are adherent to the treatment plan. Success defined as a significant decrease or elimination of the painful symptoms are measured by PPI (Present Pain Intensity)-VAS(Visual Analog Scale).? Leann M. Croft, MS PT (02/23/2006), Endometriosis Association member, Miami PT, Illinois

Other similar manual techniques are used to reduce pain, increase mobility of soft tissues and again, to ultimately reduce adhesions. These techniques can help decrease and release adhesions, which can later result in less pain and improved quality of life. Patients report such things as being able to sit for greater periods of time, participation in work and/or home activities and improved bladder, bowel symptoms and/or sexual function. During these processes, the muscles will be re-educated to return to their ?normal? position.

Scar tissue release is another crucial aspect of treating patients with endometriosis. As stated above, most women with endometriosis have undergone some abdominal or pelvic surgery. Research has shown the importance of releasing the scar with each physical therapy treatment until the return of elasticity (normal flexibility) and lack of adherence to deeper tissues.¹¹

Neural (nerve) Tension testing, as mentioned in the physical therapy evaluation, is used to identify the involvement of neural tissue. If he test is positive, then neural mobilization should be used as treatment. Neural mobilization is usually performed on the sciatic nerve (that extends through the thigh and leg) and/or pudendal nerves.⁵

Physical therapists will also work with their patient using neuromuscular re-education techniques such as contract relax or reciprocal inhibition. These techniques can be used along with or as a replacement for passive stretching. They are used as inhibition techniques to help relax the muscles. Through such techniques, the physical therapist is helping the patient re-train the muscles to return to normal position and function properly. All of the muscles in the body have a normal resting tone and function optimally at this level; however, with chronic pain such as seen with endometriosis, the muscles of the body may tighten as a guarding response.

Patients with endometriosis and PFD tend to present with tightened muscles, more specifically, the abdominal, pelvic floor, gluteal (buttock) and thigh muscles as a result of the pain and discomfort they are feeling. As a result, the muscles become hypertonic, or develop and increase in resting tone, and with time, the normal resting tone is lost. As a result, the muscles become hypertonic. This means that the muscles have increase muscle tone, which may be beyond conscious control. This muscular tension may result from guarding against pain or lead to pain. The physical therapist usually noted decreased movement and circulation to the area. The decrease in blood flow to the area will also increase the chance of MTrPs to develop. As previously stated, the trigger points may lead to localized or radiating pain. This can obviously star a vicious pain cycle.

The physical therapist helps the patient to identify the tightened/hypertonic muscles and re-educate them through proprioceptive neuromuscular facilitation (PNF), verbal cuing and biofeedback. The goal is for the patient to learn how to relax (or, down train) the muscles, which in turn helps break the pain cycle. This in conjunction with the manual therapy described previously will help the muscles to return to their normal resting tone. Transcutaneous Electrical Nerve Stimulation and electrical stimulation units can assist in pain reduction, including chronic pain.

?Yes, in the beginning because my pain was so severe, PT was extremely painful and sometimes even brought tears to my eyes. It did get better after successive sessions (probably about a month of 2x/wk!), though?the training I got in PT has helped me o keep in touch with the muscles and focusing on relaxing them. Now that the cycle of pain is broken (the major original source probably being irritable bowel syndrome or IBS and endo), I am able to maintain a low level of pelvic floor problems because of the PT. I will still do some exercises/self massage if I feel it getting out of hand.? Ashley P, Endometriosis Association member (02/21/2006), Maryland

Women with endometriosis should try to maintain their energy level by participating in some cardiovascular activity such as walking. The physical therapist should also assign stretched to be performed at home. This may include abdominal, hip, pelvic and back stretching. It is also important to perform daily relaxation and breathing exercises as well as gentle external massaging (abdomen, scars, thighs, etc?).

Once the muscles and tissue structures return to their normal tone and all of the muscles are balanced, the physical therapist will then instruct the patient on specific core stabilization exercises in order to maintain the proper muscle function. Core stabilization involves training all the muscles of the midsection (abdominal muscles, back muscles, hip flexors, etc?). Such exercises will give the patient the support needed for activities such as walking or sitting and decrease the likelihood of injuring themselves.

Examples of such exercises include bridges and planks. Weak and shortened muscles have to work much harder and require more energy than strong and normal length muscles. The physical therapist will also educate the patient on proper posture and body mechanics to maintain optimal muscle length and body alignment.

?My physical therapist was able to help me at her office through massage techniques and re-education of the muscles, and also with exercises that I could do at home. Finally I began to feel normal again. I am so thankful!!? Dale E, Endometriosis Association member, New Jersey (03/09/2006)

It is important for women with endometriosis to see a properly trained physical therapist to determine whether or not they can benefit from physical therapy. However, not all physical therapists are trained in treating pelvic floor dysfunction and symptoms related to endometriosis. Various organizations, such as the APTA Section on Women?s Health and Endometriosis Association, would be able to assist you in finding a physical therapist to meet your specific needs.

We also suggest the following questions with regards to whether or not a physical therapist has the experience in addressing the needs of patients with endometriosis.

· What patient population do you treat?

· What percentage of your patients is diagnosed with endometriosis?

· What is your success rate with this patient population?

· Do you specialize in pelvic pain treatment and PFD? How often do you treat this patient population?

· What type of training do you have in PFD?

· What techniques do you use (such as manual therapy and biofeedback)?

· Do you assess all of the pelvic muscles, including internal pelvic floor muscles?

?My clinical impression is that women with recurrent pelvic pain often respond well to physical therapy by a physical therapist that is specifically trained in the treatment of pelvic floor disorders.? Fred Howard, MS, MD (01/2001), Endometriosis Association Advisor, Professor of Obstetrics and Gynecology, University of Rochester, New York

Glossary:

Cul-de-sac: a cavity or pocket between the rectum and uterus

Pelvic Floor Muscles:

· Levator ani: pubococcygeus, puborectalis, and iliococcygeus

· Urogenital Diaphragm: Bulbocavernosus, Ischiocavernosus (converge at the perineal body), Superficial Transverse Perineus

· Pelvic Diaphragm : made up of Levator ani and coccygeus

Piriformis, Obturator Internus: Muscles which line the pelvic cavity and originate in the pelvis

PPI: Present Pain Intensity-VAS: Visual Analog Scale: A type of pain rating scale where the patient is asked to mark a tick on the line resembling their pain or rate their pain on a scale (ie from 1-10) see below:

No Pain I———————————————————————–I Worst Possible Pain

Biofeedback: Instantaneous performance-contingent feedback regarding the function of a physiological system, to increase self regulation, awareness and control

· Used in conjunction with Kegel exercises to strengthen the pelvic floor muscles and/or to learn to relax the muscles

· Helps identify the pelvic floor muscles

TENS: Transcutaneous Electrical Nerve Stimulation: The application of mild electrical stimulation using skin electrodes near or distant to an area of pain, results in interference with transmission of painful stimuli.

Myofascial Trigger Point Release: A type of hands on (manual therapy) technique that uses sustained pressure into restrictions in the fascial system to eliminate pain and restore motion and function to the body.

Proprioceptive Neuromuscular Facilitation (PNF): A type of neuromuscular re-education technique which combines muscle contraction and relaxation with passive and partner assisted stretching.

Pudendal Nerve: Referring to one of the main nerves originating from Sacral nerves S2, S3 and S4. This nerve supplies the muscles of the perineum (area between the vagina and anus) and the external genitalia.

Sacroiliac Joint: Referring to the joint found between the surfaces of the sacrum (composed of fused vertebrae of the spine giving strength and stability to the pelvis) and ilium (larger part of the hip bone). This joint is strong and weight bearing.

Viscerosomatic Reflex: An involuntary response to a stimulus relating to the viscera (organs) of the body.

Sources:

1. Denny, Elaine (2004) Women?s Experience of Endometriosis. Journal of Advanced Nursing 46(6):641-648

2. Zimlicki P, Ballweg ML (1995) The Endometriosis Sourcebook. Chicago: Contemporary Books Inc.

3. Mantle J, Haslam J, Barton S (2004) Physiotherapy in Obstetrics and Gynaecology. London, Butterworth Heinemann

4. Howard FM (2003) Chronic Pelvic Pain. Obstetrics & Gynecology. 101(3):594-611, 2003

5. Fitzgerald MP, Kotarinos R (2003) Rehabilitation of the short pelvic floor. I: Background and patient evaluation. Int Urogynecol J 14:21-268

6. Boissonault W, Goodman C (1998) Pathology Implications for the Physical Therapist. Philadelphia, W.B. Saunders Company

7. Donatelli R, Wooden M (2001) Orthopedic Physical Therapy. Philadelphia, Churchill Livingstone

8. Travell J, Simmons D (1992) The trigger point manual. Vol 1 Baltimore, Williams & Wilkins

9. Travell J, Simons D (1992) The trigger point manual. Vol 2 Baltimore, Williams & Wilkins

10. Prendergrast S, Weiss J (2003) Screening for Musculoskeletal Causes of Pelvic Pain. Clinical Obstetrics and Gynecology 46(4):773-782

11. Fitzgerald MP, Kotarinos R (2003) Rehabilitation of the short pelvic floor. II Background and patient evaluation. Int Urogynecol J 14:269-275

Niva Herzig, MS PT, received her BS in Biology from George Washington University in 1966 and her MS PT from Thomas Jefferson University in 2003. During her final clinical affiliation, she learned of pelvic floor dysfunction (in men and women), and became highly interested in this area too. She began working for Amy Stein at Beyond Basics PT in 2003, where her patient load consisted of women and men with symptoms such as pelvic pain, urinary and bowel urgency/frequency, painful intercourse, as well as orthopedic problems during pregnancy. Recently, Niva moved to Boston, MA, where she joined Marathon PT. Niva educates physicians, nurses, support groups and other therapists on the subject of pelvic floor dysfunction and pregnancy related disorders. She is a member of the Section on Women?s Health of the APTA as well as other organizations.

Amy Stein, MPT, received her BA from Washington University in St Louis, MO and her Masters in Physical Therapy from Nova Southeastern University in Ft. Lauderdale, FL. After graduate school, Amy moved to NYC, where she has been working with orthopedic/sports related injuries, pelvic floor dysfunction and women?s health for more than 7 years. Amy lectures nationwide on physical therapy and pelvic floor dysfunction. She is a member of the American Physical Therapy Association?s Section on Women?s Health, Interstitial Cystitis Association, Endometriosis Association, national Vulvodynia Association, The Women?s Sexual Health Foundation and the International Pelvic Pain Society. In 2003, she founded Beyond Basics Physical Therapy in New York City, to create a practice which takes a holistic approach to the patient?s entire well being.