The role of extrapelvic musculoskeletal impairments in women with chronic pelvic pain: Quantification to intervention

The purpose of this 3-study dissertation was to examine the role of extrapelvic musculoskeletal impairments in women with CPP. For study one and two, asymptomatic and women with CPP were recruited. Health history, psychosocial status, pain, and pelvic floor function were collected to define the population and explore relationships with muscular impairments. Muscle stiffness and pain-pressure threshold (PPT) were measured in 11 extrapelvic muscles shown as having a relationship with CPP in previous research. Stiffness of the rectus femoris, adductor longus, lumbar paraspinals and piriformis were all significantly stiffer in women with CPP as compared to the asymptomatic cohort. Additionally, there was a significant difference in PPT between groups in the majority of the muscles measured. For the CPP group, there were no significant correlations between muscle stiffness and PPT. Therefore, some extrapelvic muscles may have increased stiffness in women with CPP; however, muscle stiffness is not associated with PPT. For study 2, correlation results revealed significant, but weak and likely unimportant relationships between extrapelvic muscle stiffness and urogynecologic health history. Using an exploratory factor analysis, three clusters of impairments emerged: 1) greater pelvic floor dysfunction and psychosocial involvement, 2) increased muscle stiffness of the hips and thighs, and 3) increased muscle stiffness of the low back and abdomen. The third study examined the effect of an individualized orthopedic-based physical therapy intervention on pain intensity, extrapelvic muscle stiffness, and PPT in two women with CPP. Pelvic floor muscle function and psychosical status were also assessed before and after intervention. After intervention, the participants demonstrated significant improvements in pain and PPT for some of the extrapelvic muscles measured. Muscle stiffness measurements were significantly decreased in each participant’s primary area of pain or dysfunction. Both participants demonstrated improvement in pelvic floor function and one demonstrated improvements in central sensitization and depression symptoms. This study highlights alternate assessment and treatment of CPP beyond the pelvic floor. Clinically, extrapelvic muscle stiffness and decreased PPT are common in women with CPP, however; they do not seem to be correlated. This should be considered when clinicians prioritize interventions as extrapelvic muscle stiffness may not be a pain generating impairment. Additionally, intervening upon extrapelvic impairments may be beneficial in women with CPP.

Preliminary symptom categorization suggests that women with CPP who present with greater pelvic floor dysfunction and psychosocial involvement may be more appropriately streamlined to see a pelvic health physical therapist versus those who present with stiffness of the hips and thighs or low back and abdomen. If clinicians can identify which women with CPP necessitate specialized pelvic health physical therapy, this might improve access to care for those who do not need intrapelvic intervention. Additionally, the utilization of an extrapelvic intervention on CPP resulted in positive outcomes in pelvic floor pain and function for those with CPP; this challenges the current paradigm necessitating intravaginal physical therapy for all women with CPP. Physical therapists have the appropriate set of skills necessary to treat extrapelvic musculoskeletal impairments of CPP. However, future research is needed to better understand the role specific musculoskeletal impairments have on pain and function, beyond extrapelvic muscle stiffness. This information would help guide the variables of interest for future intervention trials. By identifying other common musculoskeletal impairments in this population, the impairment categories of CPP could become more robust and help guide treatment of the impairment sequelae. Subsequent research examining the effects of singular extrapelvic intervention strategies, such as the ones used in the third study, are necessary to understand their effects not only on the musculoskeletal impairment but also on pain and pelvic floor function.