Transcript of VPS Podcast 4 - Physiotherapy treatment for vulval pain: a presentation given by Helen Forth

Slide 9 (09:00)    Pelvic floor muscle rehabilitation

What might pelvic floor muscle rehabilitation look like? Well, the assessment really is the cornerstone for everything that we should be doing for you as physiotherapists. That initially will be a digital vaginal examination of your pelvic floor muscles. It may also involve a rectal examination if that’s appropriate – it’s not for everybody. And I’ve said ideally, an EMG assessment: it’s not always indicated, and it’s not always necessary. Not everybody has the equipment available. [Responding to audience question] EMG – sorry, is ‘electromyographic’, so when I come on to talk about biofeedback, I’ll talk a little bit more about it, but it’s a slightly more scientific, I suppose, way of looking at the pelvic floor muscle function. If biofeedback is going to be part of the treatment that you do for a woman with vulval pain, then usually EMG is the method that’s used to do that. Other things that the pelvic floor rehabilitation should, or will likely include, is normalising pelvic floor muscle resting tone, improving somebody’s ability to relax or let go of their pelvic floor. And actually Dr Baranowski talked about people who carry tension in their pelvic floor muscles in the same way that some of us might carry tension in our shoulders, and that gives us headaches -  there is definitely a group of women (and men, I suspect), who carry tension in their pelvic floor and in their pelvis. That’s very, very relevant and very important to remember.

Also, we’re going to be looking at improving the control and coordination of the pelvic floor muscles, working on appropriate strengthening, so using the muscles effectively, and gaining the strength, so that it’s there when you need it, and improving stability of the pelvic floor, so that ties in with the resting tone aspect. And then also a home exercise programme as well, because obviously, if you’re coming to see a physiotherapist for treatment intermittently perhaps – it might be once a week, it might be once a month, it might be once every couple of months – you’re only going to get a limited benefit from those sessions. You need to be doing some work on your pelvic floor, and on pelvic floor function through exercise or biofeedback at home as well if you’re going to get the most benefit from seeing a physiotherapist.

Slide 10 (11:22)    Pelvic floor muscle rehabilitation: Self help measures

From a self-help point of view, I figure this is what you’re probably more interested in: what can I do to help myself? If you’re going to work on your pelvic floor function, I would say that it is really important to have your pelvic floor assessed properly, but once it’s been assessed and you have a home exercise programme, from a physio point of view, it’s really important that that exercise programme is individualised. So I’m not going to stand here and tell you today that you need to go away and do ten pelvic floor contractions once a day, three times a day, however many times it might be. It’s a very individual thing, and it needs to depend on what your pelvic floor is capable of, so when your pelvic floor’s being assessed, the physiotherapist will look at how strong the muscles are, they’ll look at what the endurance of your pelvic floor is like, so not only how much power can you generate with your pelvic floor, but also how long can you sustain that for, and how many repetitions are you able to do, and that’s a really individual thing. And so, this business of ‘every contraction timed’ comes into that: it’s not a case of going away and doing a few contractions here and there whenever you think about it. It’s actually important that when you’re doing your pelvic floor exercises you are concentrating on what you’re doing, and paying some attention to what you’re doing.

I tend to focus more on the endurance aspect of the pelvic floor and that is sometimes known as ‘slow twitch’, rather than looking at power, because actually, if you contract your pelvic floor very powerfully, some women then find it incredibly difficult to let go of it effectively, particularly if they’re trying to do several repetitions where they’re squeezing their pelvic floor as hard as they possibly can. It’s interesting, because there are some women who get really good relaxation after a full contraction of their pelvic floor, but just through experience, I’ve found that if people are trying to do too quick repetitions with pelvic floor exercises, their resting tone actually creeps up, rather than them being able to fully release their pelvic floor. So, that’s something that I tend to focus on. In terms of how much to be doing from a pelvic floor point of view, there is some consensus out there that if you’re trying to strengthen the pelvic floor muscles, then three sets of pelvic floor exercises a day is something to aim for, but we’re not always trying to increase the strength of the pelvic floor in women who’ve got vulval pain – sometimes we are, but not always. So again, that would be individualised, actually – the frequency of the exercises.

I would also say that pelvic floor work also means general awareness of your pelvic floor muscle activity, so this ties in with what I was saying about some people having a tendency to carry tension in their pelvic floor. Actually being aware of that, and actively trying to do something about it, can be really useful, so that might mean that at times when you’re particularly stressed, or busy, actually just ‘tuning in’ for want of a better word with your pelvic floor and thinking: ‘What am I doing with those muscles? Have I contracted them without realising that that’s what I’ve done? Am I carrying tension there? Am I able to release off that tension?’ And actually, often, if you are able to release off that tension, you find that you get an improvement in your pain.

If that’s all sounding a little bit alien to you, and you’re thinking, ‘Well, how can I release my pelvic floor if it’s behaving abnormally?’, that’s where physio and the re-education and the biofeedback side of things really come into play, so don’t think it’s something that you should instantly be able to grasp and understand and actually do, because if may well take several sessions of input from a physio to be able to enable you to do that.