Chronic Pelvic Pain Evidence Informed Protocol


Abstract

Chronic Pelvic Pain Syndrome (CPPS) is pain in the area below the belly button and between the hips lasting six months or longer. Chronic Pelvic Pain Syndrome can be its own condition or symptom of another disease. CPPS is a complicated situation requiring a combination approach to healing. Treatment is symptomatic abortive therapy to reduce acute exacerbations. There is currently little research on yoga therapy and chronic pelvic pain syndrome. Overall research on chronic pelvic pain syndrome appears to be lacking rigger. Chronic pelvic pain syndrome is a problem for health care providers because it is misunderstood and poorly managed. CPPS has an unclear etiology, complex natural history and poor response to treatment plans of care. Arnold Kegel, in 1950 was the first author to talk about PFM (Pelvic Floor Muscles) and have been recommended for some time. In 1963 Jones suggested that anatomic characteristics could influence the performance of PFM. In 1984 the introduction of biofeedback provided confirmation of the use of Kegel exercise in changing PFM function. In the 1990’s randomized control trials began related to PFM training. CPPS is a public health problem for women throughout the developed world.

Introduction

One in seven women suffer from CPPS outpatient visits in the United States for Chronic Pelvic Pain Syndrome (CPPS) is estimated at $881.5 million per year for women between the ages of eighteen to fifty (Mathias, 1996).  Similar to other chronic pain conditions CPPS may lead to prolonged suffering and a lifetime of therapies while affecting their personal and professional relationships and leading to loss of employment or disability. To optimally manage this condition a variety of health care professionals are needed. A CPPS patient may see a gynecologist, gastroenterologist, urogynecologist, physiatrist, and a physical therapist. It is suggested that the patient and their family be educated on the multifactorial approach to chronic pain. Patients should avoid stressful situations and poor posture. It is suggested that exercise, good sleep hygiene, balanced meals, biofeedback and relaxation techniques may be beneficial to CPPS (Singh, 2015).

The Literature Review

Having a good working relationship between the clinician and patient is a necessity due to the compounding nature of CPPS. A treatment plan should be tailored to the individual with a goal to reduce symptoms and improve the quality of life. While managing the pain using a contemporary approach of both psychological and physical therapy is needed, if a particular cause is found treating this condition as well. The complexity of the pelvis and the anatomical proximity of pelvic visceral means that symptoms frequently overlap traditional medical specialties, leading to diagnostic delay (Vincent, 2008).  Inadequate treatment happens to twenty-five percent of women and often after three to four years they still do not have a diagnosis. During this time these women saw a forty-five percent productivity reduction at work.  CPPS can present anywhere along a spectrum of organ-specific to regional to systematic pain (Vincent, 2008).

CPPS pain symptoms can range from mild to annoying to severe where the patient is missing work, cannot sleep and cannot exercise. Standing for extended periods of time may intensify symptoms; symptoms may be relieved by lying down. Some symptoms that may accompany CPPS are severe and cover a broad range of constant pain, intermittent pain, dull aching pain, sharp pains or cramping, pressure or heaviness deep in the pelvis, pain during intercourse, pain while having a bowel movement or urinating, pain when you sit for extended periods of time.  There is no gold standard diagnostic test for CPPS; it is a diagnosis of exclusion (Sherkhane, 2013). Causes for this condition are complex as there may not be one single cause but many amongst a wide range of conditions including reproductive, GI, urologic and neuromuscular disorders. Diagnosis for CPPS is usually a process of elimination. A detailed past health history, family history, journal of pain and symptoms, pelvic exam, lab tests (infection, blood count cells and UTI), ultrasound, x-rays, CT scans, musculoskeletal (piriformis syndrome, dysfunction of obturator muscle or fascial, herniated disc, dysfunction of psoas or flexion abduction and external rotation)  and MRI’s (Neis, 2009).  What women want out of a CPPS consultation is personal care, to be understood, to be taken seriously, explanation and reassurance (Vincent, 2008).

The pharmacology of CPPS generally starts with pain relievers such as aspirin, ibuprofen, and acetaminophen. It is common to prescribe hormone treatment (birth control) and/or antibiotics (tizanidine) and/or antidepressants (doxepin, desipramine, protriptyline, buspirone).  Other therapies prescribed are physical therapy (stretching, massage, relaxation techniques, TENS-transcutaneous electrical nerve stimulation), Neurostimulation (spinal cord stimulation), trigger point injections, psychotherapy (working on root cause cognitive behavioral therapy), biofeedback, acupuncture, meditation and deep breathing. If surgery is an option the most popular surgeries used are laparoscopy and hysterectomy. Other surgery procedures may be presacral neurectomy (superior hypogastric plexus excision), paracervical denervation (laparoscopic uterine nerve ablation) and uterovaginal ganglion excision (inferior hypogastric plexus excision) (Singh, 2015).  Tizanidine is not a conventional method; the theory is that it may provide improved inhibitory function in the central nervous system. Selective Serotonin Reuptake Inhibitors (SSRI’s) such as Prozac, Paxil and Zoloft are commonly prescribed to CPPS patients (Singh, 2015).

Pelvic floor muscle (PFM) function is a group of muscles and connective tissue that extends as a sling across the base of the pelvis (medical dictionary). It is comprised of two layers, the superficial perineal muscles and the deep pelvic diaphragm providing support for the pelvic organs, the bladder and elements of the spine.  Stiff muscle fibers have a decreased ability to generate power. Overactive pelvic floor muscle (OPFM), experience muscular weakness and early time-to-fatigue. PFM have a higher percentage of slow fibers to maintain its tone and contraction, except during voiding.  Alternative methods, such as Pilates and Yoga may be an effective tool to improve the strength of the body core musculature (Marques, 2010).

Comorbidities for CPPS are depression. The association between abuse, psychological morbidity, pathology, and CPPS are sufficiently consistent and suggest that they may well be causally related (Latthe, 2006).  CPPS is challenging treatment strategies most successfully if they are undertaken in a broader scope of an integrated care model (Engeler, 2013).

 

Pancamaya Model

Yoga therapy can be used as a self-treatment tool for CPPS.

Annamaya Kosha- Muscle guarding is a sign of a tight pelvic floor and is a maladaptive self-protection process that leads to injury and increased pain. Nerve pain leads to muscle atrophy which may cause less blood flow. The diaphragm works in coordination with the pelvic floor. Think of the autonomic nervous system as yin and yang. The sympathetic nervous system is our flight, fight, and freeze pain is overactive here as our run from the bear chemicals is in overdrive.  The parasympathetic nervous system is our rest, and digest and our chill out chemicals are working. Vigorous yoga with lots of sun salutations and lunging is not a good fit for CPPS. A treatment plan using gentle and restorative yoga, while using language on letting go,  and allowing the nervous system to relax is more efficient.

Pranamaya Kosha- Three part breath and letting go breath, works well with this condition. Shallow breathing deprives organs, and muscles of oxygen and is a common trait in those suffering from chronic pain thus the yoga therapist can guide the patient into conscious pranayama. There is a decrease in Apana vayu energy along with chakras one, two and three. Focusing on expelling exhalation and what is not needed, grounding and cleansing to support the need for becoming calm and rooted.

Manomaya Kosha- Starting with tamas which is a dull mind that is hiding awareness, fear interprets experience and hinders self-inquiry and bringing chakras one and two into balance (imbalance, disorder, anxiety, inactive). Rajas will eventually happen as anger, anxiety, frustration, aggression, and boredom seep in as you balance chakra three.  Grounding meditation while working on survival, emotions/suppression, and breaking powerlessness. Managing the emotions can be done through meditation, chanting, mudra, journaling and so on.

Vijinanamaya Kosha- Discussing ahimsa “do no harm” teaching the patient to not push to discomfort because they will gain more by listening to the boundaries their body is telling them. Learning to parent ourselves through listening to the body and mind with kindness. Ishwara Pranidhana is letting go of control and practicing humility so looking at your yoga practice not as what it can do for you but approaching it as a practice in the spirit of an offering. This niyama is a way for us to listen to our minds and to dissolve the endless agitations that may live there.  Swadhyaya letting go of blame and practicing curiosity this can be looked as self-study that uncovers our strengths. It can also be a way to ruthlessly reveal our weakness such as habit patterns and negative tendencies. While this may be uncomfortable work the grace of it is locating the soft spot and not beating ourselves up for what we perceived as a fatal flaw. Learning to welcome and accept our limitations as we do this we get close enough to ourselves to see the roots of our anger, impatience, and self-loathing and instead meet it with compassion for the conditions that molded the behaviors and beliefs in the first place. Aparigraha is letting go of expectation and practicing letting go or flowing with whatever comes our way it is a way for us to practice letting go of some of the physical, emotional and mental baggage that we amass during our journey. We let go it opens up our energy so that something new can come allowing us to grow. It is cleaning out the clutter physically and emotionally, forgiving ourselves and others, observing nature enabling it to teach us to flow along the journey and to learn about our breathtaking it on and off the mat.

Anandamaya Kosha as you focus on security, self-nourishment and self-empowerment then fear and anxiety are released, inner nourishment increases and clarity arises. Sensations of comfort and bliss can stem from the pelvis while radiance unfolds naturally. An inner peace and harmony are obtained.

Yoga has been found to be effective in reducing pain intensity and improving function; however, studies do not mention the sampling methods used (Sutar, 2016).

Evidence Informed Protocol

A yoga therapist can help by addressing a four process treatment plan creating awareness, releasing and relaxing the PFM, engaging PFM, and using the chakras and koshas (Prosko, 2016).  First address security and survival, then self-nourishment and desire, finally self-empowerment and assertiveness. Poses such as knees to chest, twists, pigeon, child’s, supine butterfly, happy baby, third world squat are a few asana to start.  First teach the client about the bones, muscles, and joints of the pelvis. Creates a foundation on which to build further concepts off and gives us a working language for the workshop. The pelvic floor is the antagonist of breathing muscles and helps with breathing coordination.  Two pubic symphysis joints (PSJ,) note this is not a real joint; it is a fibrous cartilage that doesn’t allow for much movement, two sacroiliac articulations (SA)-real joints between the pelvis and sacrum, the fifth joint is between the sacrum and coccyx. Coccyx can move forward and back and which affects the tension in the pelvic floor muscles. Then move into creating flexibility for the pelvic floor. Many pelvises are tight, so first, we will talk about flexibility. A gripped muscle doesn’t allow strength to take hold which is why flexibility is next. Some asana may be the cow-face pose, pigeon pose, cobbler’s pose, supine pigeon, supported bridge. Develop strength to hold the organs in, to create power to build a strong core. Some asana may be Mountain with a block, chair pose, bridge pose, one-legged bridge, warrior 1,2,3, triangle pose, goddess pose, cat/cow, crescent lunge. Putting it all together and creating a visual picture and felt a sense as a way to embrace the relevance of the pelvic floor.

Discussion

Even though research is scarce for CPPS, it is important that every female who presents to a health professional with pain at whatever age be taken seriously. Validating the experience, managing chronic pain, managing musculoskeletal and psychological secondary consequences must be maintained and is best done within a multidisciplinary setting, will reduce the burden of chronic pelvic pain in women. Chronic pelvic pain is a common disabling condition that has been poorly studied. There is uncertainty about the causes and best treatment (Latthe, 2006). Studies designed with long-term follow-up would be useful in establishing yoga-based intervention as a treatment modality for functional pain disorders.  Soothing pitta imbalances and centering vata imbalances is critical while cultivating a sense of comfort and inner nourishment is an effective antidote for issues of codependency and compulsive behaviors.

 References

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