This is a transcript of the soundtrack from VPS Podcast 4, a live recording of a presentation given by Women’s Health physiotherapist Helen Forth at the VPS Super Workshop in December 2010. The full slide presentation can be viewed at Physiotherapy treatment for vulval pain: a presentation given by Helen Forth.
A list of the papers cited in the presentation is available at References for Physiotherapy for vulval pain: a presentation given by Helen Forth.
Timings of each slide are provided in order to aid quick location.
[Editor’s note, October 2015: Helen Forth informs us that since this presentation was recorded in 2010, her approach as a physiotherapist to treating vulval pain has changed somewhat in focus, and she would now place much more emphasis on pelvic floor muscle relaxation and trigger point release, and much less on pelvic floor exercises and biofeedback.]
Slide 1 (00:00) Physiotherapy treatment for vulval pain
I am the clinical lead for Women’s Health Physiotherapy at the Royal Free [the Royal Free Hospital, London, UK]. We have quite a big and fairly unusual Women’s Health Physiotherapy service there at the Royal Free. I run quite a big service, with a big team of physios, so we are, I suppose, by default, a little bit of a centre in terms of receiving referrals for women with vulval pain who need physiotherapy treatment – partly that’s because we now have three consultants who actually specialise in treating vulval conditions, and have a special interest in vulval pain, so I will acknowledge that we do come at this from a slightly unusual perspective. What I’m going to talk about today is very much our approach at the Royal Free. There are definitely other centres that are taking a very similar approach now, and I think that physiotherapy in this area is really growing, and has really grown and developed in the last ten years. And actually, anybody who thinks that physios might not be interested or relevant as far as vulval pain is concerned… Can I just ask those of you who are Women’s Health physios to pop a hand up, because there’s quite a lot of you here…? Yes – thanks, guys! [Laughs]
Slide 2 (01:08) Content of presentation
So that I don’t run out of time, I shall move on, but this is the stuff that I’m hoping to cover. I do want to just give a little bit of an overview about what Women’s Health Physiotherapy actually is, and then also talk about what physiotherapy treatment might involve. This will consist of all or some of the things that you can see listed there, so perhaps pelvic floor muscle rehabilitation, perhaps biofeedback, something that tends to get called ‘desensitisation’ now (I’ll elaborate on that a little bit as I go along), possibly relaxation, and then also assessment and treatment of associated problems. And actually Andrew [Andrew Baranowski, a pain management consultant and earlier speaker at the VPS Super Workshop 2010], who spoke to us earlier, spoke very eloquently about the fact that there is a massive overlap with other conditions: we do see a lot of women who’ve also got bladder or bowel problems, or other problems with their musculoskeletal system, whether it’s back pain, or pelvic pain, or a combination of those things, so I’m going to touch a little bit on that as well. Then also, because I think you might be interested, I want to talk a little bit about whether physiotherapy works or not – whether we know whether physiotherapy works or not, and what research is out there at the moment.
Slide 3 (02:17) What is Women’s Health Physiotherapy?
In terms of just thinking about what Women’s Health Physiotherapy is – I do apologise to those of you who are Women’s Health physios – hopefully you know all of this! [Laughs] ‘Physiotherapy uses physical approaches to promote, maintain and restore physical, psychological and social wellbeing…’ It’s science-based, it’s ‘committed to extending, applying, evaluating and reviewing the evidence that underpins and informs its practice and delivery. The exercise of clinical judgment and informed interpretation is at its core.’ That’s taken from the Chartered Society of Physiotherapy, which is our professional governing body.
Slide 4 (02:53) What is Women’s Health Physiotherapy? (continued)
So, what is a Women’s Health Physiotherapist? ACPWH, which stands for the Association of Chartered Physiotherapists in Women’s Health is a physiotherapy special interest group. It comes under the umbrella of the Chartered Society of Physiotherapy, but it’s a subgroup of physiotherapists who specialise in working in women’s health. To be a member of ACPWH, a postgraduate qualification in Women’s Health Physiotherapy or continence is required, so physiotherapists who are members of ACPWH are specialists who have undergone accredited courses in this particular area. Members of ACPWH specialise in the physiotherapeutic care of women in relation to a whole bunch of things, but childbirth may be part of that, treatment of incontinence, both male and female, and in the care of women undergoing gynaecological surgery. Along with that, although it’s not part of the formal definition, is pelvic pain, and vulval pain as well. In Gynaecology ‘professional expertise, combined with sensitivity and understanding is invaluable to patients… Some members of ACPWH take part in psychosexual counselling workshops which enable them to help patients with sexual problems’, and obviously that’s very relevant for a lot of you today.
Slide 5 (04:15) Why treat vulval pain with Physiotherapy?
Why treat vulval pain with physiotherapy? At the Royal Free, I have to say that our approach has come as a result of more than ten years of really close collaboration between us as Women’s Health Physiotherapists and our consultants, who we work very closely with. We found anecdotally that we were getting very good results from the approach that we were using in terms of treating women with vulval pain. That actually from a personal point of view led me to conduct my Master’s thesis: my research for my Master’s dissertation was actually looking at the effectiveness of physio treatment for vulval pain, really because we wanted to be able to justify what we were doing and to be able to back up what we thought we knew, which was that it can be very effective for some women.
Why else might physiotherapy be relevant? Well, there’s been a lot of papers in the last few years which have shown us that pelvic floor muscle hypertonicity (and what that means is overactivity), or too much tone in the pelvic floor, can often be found in women who’ve got vulval pain, and that can be found both digitally, so when you’re examined with a digit, i.e. finger, and also on EMG, and I’ll talk a little bit about EMG in a moment. Poor pelvic floor muscle control, lower strength and endurance is often also noted. Why would you have weak muscles if they’re overactive? It sounds a little bit like those two things ought not to go together, but in fact when you’ve got high muscle resting tone, it’s then very difficult to use a muscle effectively and to its full ability. It’s a bit like starting from here and trying to contract your arm further – it’s not as easy as if you’ve got the full range of movement there available to you. Also, specific pelvic floor muscle myofascial trigger points, which Brent [Brent Osborn-Smith, who spoke earlier on osteopathy and acupuncture at the VPS Super Workshop 2010] also touched on, may be found, as may reduced circulation and mobility of the tissues, and that’s something that physiotherapy can help with as well. I’ve put a few references in there. When this presentation gets put on the website, I’ll produce a proper reference list for you, so that if anybody wants to actually go away and look at any of these studies, then you can.
[Editor’s note: a full list of references for the papers cited in this presentation is now available at References for VPS Podcast 4 – Physiotherapy for vulval pain: a presentation given by Helen Forth.]
Slide 6 (06:30) The pelvic floor muscles (diagram)
I just thought it was worth including a couple of slides of the pelvic floor muscles, really just to orientate you and help you to understand why they’re so relevant. I’m not going to talk much about them, but I’m hoping that you can see fairly clearly. The muscle that we’re particularly interested in is labelled there at the bottom of the slide – you can see puborectalis, iliococcygeus are part of the pelvic floor, and are often the muscles where these trigger points that we’ve talked about can be found. The pelvic floor is a big group of muscles: it runs all the way from the pubic bone at the front of the pelvis, and then attaches onto the bottom of the spine, so the sacrum and the coccyx.
Slide 7 (07:11) The pelvic floor muscles (continued)
It also spans the whole width of the pelvis as well, so it’s not just a small muscle surrounding the vagina, it spans all the way out, covering a big distance, forming a bowl shape – some people like to describe it as a ‘hammock’ – I’m not sure that those descriptions work, actually, because it’s not perhaps quite as round as that alludes to, but gives you the idea that it provides support to the pelvic organs anyway.
Slide 8 (07:38) The role of the Physiotherapist in treating vulval pain
The role of a physiotherapist in treating vulval pain: I’ve actually taken this from a study published by somebody called Sophie Bergeron, who’s quite a prominent researcher in this field. She’s based out in Canada, and she tells us that the role of the physiotherapist in treating vulval pain should be to increase pelvic floor muscle awareness and proprioception, to improve pelvic floor muscle strength, speed, endurance and muscle discrimination, so that just means your ability to isolate your pelvic floor muscles, to reduce pelvic floor muscle hypertonicity, so that’s the overactivity or the increase in tension that I mentioned, and to improve voluntary relaxation of the pelvic floor. It’s also to improve elasticity of the tissues at the vaginal opening and to reduce fear of vaginal penetration. I’ve also added counselling skills to the bottom of that list because I do think that that’s a very important aspect of the physiotherapist’s role. All physiotherapists are trained to listen, and that’s all that counselling means, if you take it right back. I’m not saying that physiotherapy can take the place of psychosexual counselling, or formal counselling, if that’s indicated, but really just to say that there is a counselling benefit there through seeing a physiotherapist, and being listened to, and I think you’ve heard that actually from all of us, that that’s a very important aspect of what as professionals we should be doing for you.
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.
Slide 11 (15:05) Pelvic floor muscle rehabilitation: Myofascial trigger point release
OK, so just a little bit more about trigger points… I’ve just included a definition here, which is that myofascial trigger points, so that basically just means trigger points within muscle, are ‘hyperirritable spots in skeletal muscle associated with a hypersensitive palpable nodule’, so you can actually feel them, ‘in a taut band’ of muscle. That trigger point tends to be painful on palpation, and it’s worth saying that myofascial trigger points often refer and reproduce pain when palpated. I can’t remember who said it already this morning, but somebody did, that often when you press on a trigger point, a patient will say: ‘That’s my pain’, so you know that that’s the spot. Not only can you as a therapist feel it, but the patient knows that that’s reproducing their symptoms. We know that myofascial trigger points are really common in the pelvic floor muscles in women who’ve got any type of chronic pelvic pain, not just vulval pain actually, but other types as well. Myofascial trigger points can be released manually, by the treating physiotherapist, or osteopath, or whoever you’re seeing, and also by the patient themselves at home. And actually, it’s one of the things we often do, is teach patients how to do trigger point release themselves so that they get some lasting benefit from the therapy that we do with them in clinic. If you can release off trigger points, effectively that will often lead to a reduction in this level of resting tone within the pelvic floor.
Slide 12 (16:32) Pelvic floor muscle: myofascial trigger points
I’ve just included a picture – just a couple of examples of where there might be trigger points within the pelvic floor. I’m actually most interested, and I think you’ll be most interested, in this picture up here. [She indicates the slide, which shows the referral pattern of pelvic floor muscle trigger points in the external anal sphincter and coccygeus muscles.] These crosses are areas where it’s quite common to find trigger points within the pelvic floor, and as far as the referral pattern for those trigger points is concerned, it can be in this region. There are other trigger points in surrounding areas that can be very relevant as well, but these are particularly significant in terms of looking at pelvic floor activity.
Slide 13 (17:09) Pelvic floor muscle: myofascial trigger points – self help
From a self-help point of view with trigger points, I would say that trigger point release should really be done with teaching and guidance from a physiotherapist – again, it’s not something to go away and just have a go at. But self-release can be really effective. It’s really important, I feel, to do this within the limits of your pain. You don’t want to be doing something that’s going to cause you so much pain that it sort of sets up that vicious cycle of expectation and oversensitivity, and thinking that it’s always got to be painful to insert something into the vagina, which it doesn’t always have to be. I think trying to do this sort of self-help stuff within the limits of what you’re able to cope with and manage is actually really important from that point of view. Generally, women find it easier to do self trigger point release in their pelvic floor using their thumb: it’s just easier to reach for most people, although there are some quite deep trigger points that you may not be able to get to with your thumb, and you might need to find a way to get your index finger to reach. It’s quite tricky: you do have to be quite mobile and dextrous to be able to do it, and that’s why it’s quite important to try and do it under the guidance and the supervision of a physiotherapist. When you’re releasing a trigger point, you only normally need to apply pressure for somewhere between one and two minutes. You should find that if you’ve hit the spot, pain will decrease and the muscle will release. That’s basics, anyway, in terms of how trigger point release might work.
Slide 14 (18:44) Biofeedback
Something you might be even more keen to hear about is biofeedback. It’s become really popular, and there’s been some really good work done looking at its effectiveness. I have again just included a definition and a basic overview of what it means. It is a method of measuring a biological process, actually any type of biological process, but examples might be heart rate, or muscle tension, and feeding this signal back to the patient, through the use of either a visual or a sound signal. You’ll see when I get some of the bits of equipment out, that some of the biofeedback that we do as physiotherapists might involve a probe that’s inserted into the vagina that’s attached to either, if you’re in a clinic, a computer with a screen, where you get graphs on the screen that show you what’s going on with your pelvic floor, or it might be a little hand-held unit that’s got lights that light up, or sounds, or beeps that go off, that show you how strongly you’re contracting your muscles, or how well you’re relaxing them, and that extra feedback is a really good way of helping you to learn how to effectively use your pelvic floor. It’s just an additional method, really, of reinforcing what it is we’re trying to get you to learn from that point of view. The level of the signal reflects the intensity of the biological function, which in this case is the muscle activity. The idea is that to alleviate symptoms, you as a patient are trying to take some control over this biological process. The most commonly used form of biofeedback for vulval pain would be EMG biofeedback of the pelvic floor muscles.
Slide 15 (20:28) Biofeedback (continued)
An EMG sensor or probe would be placed into the vagina. This detects the level of activity in the pelvic floor muscle, and as I was saying, with vulval pain, that pelvic floor will tend to be overactive at rest. These sensors are then attached to the computer, which gives a visual display of the intensity of the contraction when you’re either contracting or relaxing the pelvic floor muscle, and that instant feedback which is shown on either the display screen or this little handheld unit will obviously help to encourage and motivate you to continue with that method of therapy. So, that’s the theory behind it.
Slide 16 (21:06) Biofeedback (continued)
Biofeedback, as I’ve touched on, can be used in either the clinic or home setting. Clinic use is often for initial assessment and detailed readings of pelvic floor muscle resting tone, muscle strength and endurance; home use is often really effective for ongoing treatment, and as I’ve said, that’s often via a smaller hand-held unit. People sometimes wonder about what the probes look like, and I’ve actually brought some with me that I’m going to show you, and you can perhaps pass around at the end if you want to. There has been development of a really good EMG anal probe that can be used vaginally really effectively for this, and the anal probes are much smaller than the vaginal probes, so if people have had previous attempts at biofeedback and have found they’ve not been able to insert vaginal probes, and there weren’t anal probes available to you at that point, this might be something that’s worth trying. There’s a particular probe that I’ll show you, that’s actually been CE-marked as being effective and suitable for vaginal use, and that’s really been helpful in terms of being able to use biofeedback for more patients.
Slide 17 (22:16) Biofeedback (graphs)
I’ve just included a couple of graphs to give you an idea of the sort of things that you might see if you’re doing biofeedback, and the kind of readings and things that your physio might be interested in. The one at the top, here [she indicates on the slide] is a measurement of somebody’s pelvic floor muscle resting tone, and this is just very slightly increased, and what you can see is that this line is quite spiky, and some people might use the word ‘unstable’ to describe that. It means that when the muscle is resting, or you think your muscle is resting, there is some ongoing activity there. There is always going to be some activity within the pelvic floor when you think it’s relaxed, but we have measures of normal limits of resting tone, so this graph is just showing a slightly above normal level of resting tone there. The one underneath is just showing somebody trying to do a 10 second hold of a pelvic floor squeeze, and they’re trying to do this at 50% of their maximum contraction. You may remember that I was saying that I often don’t get people to work fully, to work maximally, because it can then be quite difficult if you’ve got abnormal muscle function to be able to let go well, so this is an example of somebody trying to do a slow squeeze that they’re trying to sustain for 10 seconds. You can see she was struggling a little bit. You should be trying to follow the Yellow Brick Road, basically, when you’re using these sorts of templates, and you can see that this lady was just struggling a little bit to maintain her pelvic floor activity at that level. So, I hope that’s helpful, just to see what it might look like. You might find that your physio prints off these sort of graphs, gives them to you to take away and pin to your fridge to act as motivation, or might put copies of them in your notes, and they can be a really useful comparison for when you come back for more sessions, to see how your muscle activity has changed.
Slide 18 (24:11) Biofeedback equipment
Excuse the slightly blurry pictures, but I just wanted to include a few bits of equipment here for you to actually be able to see them. In clinic use, you’ll probably see something like this, which is a desktop PC that’s got all the bits of kit attached to it. The screen is where you would see those graphs that I was just showing you. We have one of these at the Royal Free. A lot of Women’s Health Physiotherapy departments now have this particular piece of kit – there are other bits out there, but just as an example of something that’s quite commonly used. This is an example of a home unit that you might see, and in fact I’ve got one with me that you can have a look at if you’re interested, and then these are some of the probes. So, the anal one that I was talking about that’s smaller than a lot of the vaginal probes is this: something called an ‘Anuform’. They’re not particularly friendly-looking, and I apologise for that. I think it’s something that does need a bit of work. There is actually some quite interesting development going on at the moment looking at probes for biofeedback specifically for women who’ve got pain syndromes, and in fact I know of somebody who’s in the process of developing – I think it’s due to come out next year – a probe that’s actually made of foam rather than a hard plastic probe, which sounds like it ought to be much more comfortable to use if you’ve got pain, so watch this space as far as that’s concerned.
Slide 19 (25:38) Biofeedback self-help measures
Biofeedback self-help: so, a home biofeedback unit – from us at the Royal Free, anyway, we can loan out home units to patients to trial. A lot of patients do go ahead and buy them themselves. They’re not massively expensive to buy: about £85 if you buy them as a patient, because you get them VAT-free. If we buy them for you, actually we get charged VAT, so it’s more expensive that way round – it’s actually better to buy it directly as a patient, and there are several companies who produce bits of kit that can be used. Again, I would say use them under guidance of a physiotherapist rather than going off and buying your own kit and just having a go at using it without any supervision – I would really encourage you to get it looked at properly and to know that you’re using it effectively and safely and so on. The home kits can be used with the same probes that we use with you when we do biofeedback with you in a clinic setting, which is good, and the biofeedback units can be set so that they match your capabilities in terms of the length of time you’re able to hold a pelvic floor contraction for and the number of repetitions you’re able to do, and so on, so that can work really well. They display resting tone and contraction strength, and then as I was saying before, you can have a combination of lights and noises and numbers that provide feedback, that can really help you to learn how to use your pelvic floor effectively.
Slide 20 (27:09) Desensitisation
Just quickly, desensitisation basically just means decreasing hypersensitivity, and Andrew talked earlier about how we can have a pain memory – we can become oversensitive if we’ve got pain. You can start to learn that any kind of touch or stimulation in that part of your body is going to be painful, and desensitisation is a technique that’s used to help to overcome that, really. It includes things like self-examination; it includes gradual guided insertion of probes, so you might start off by using one of the smaller anal probes and then progress to using a bigger vaginal probe. It may include the use of vaginal dilators, and I’m sorry I haven’t got time to elaborate hugely on all of this. It may be required before you do EMG biofeedback: it may be that you need to go through some desensitisation work before you’re at a point where you can tolerate inserting and keeping in place a vaginal probe for the length of time that’s required to do the biofeedback, so sometimes this does have to come first. It should always be done within the limits of the patient’s pain, and obviously what you’re aiming for is a positive experience of insertion. If it hurts when you try to insert something, all that’s going to do is reinforce the idea that it’s always going to hurt, so I always say to patients: if it hurts, stop! I think that’s really important. And as I said, under physio guidance.
Slide 21 (28:41) Desensitisation (continued)
This is just a picture that shows some of the vaginal dilators. I have to say I don’t use these that often: it’s not normally that somebody has an anatomically small vagina that needs stretching – I mean, it can be a problem for some people, but in terms of the patient group that I see… But sometimes there is a place for dilators, and we do sometimes recommend their use. I think they can be really helpful when they’re used for desensitisation purposes, because they come in different sizes, and you can sort of gradually work your way through the options that are there from a size point of view. Again, they’re not very friendly-looking, and I do apologise for that. They’re very clinical.
Slide 22 (29:22) Relaxation and lifestyle
Relaxation and lifestyle are just worth touching on. I do find that there is some benefit from using general relaxation techniques as part of the physio approach. We use something called the Laura Mitchell method quite a lot, which is really just a whole body technique, where what you’re trying to do is to take the body out of positions that are classically associated with stress and tension into positions associated with relaxation, the idea being that if you can improve your general body awareness, and reduce tension in other parts of your body, that you will get some carryover into your pelvic floor, and some increased awareness into your pelvic floor muscles. We tend to include general exercise advice in what we do, and that may be recommending that somebody include something like yoga or Pilates in their routine. Some people hate yoga, some people love it, but I think just some sort of exercise that improves your general body awareness is really useful. Pilates very much focuses on pelvic floor muscle awareness and activity, and so I think for some women, there’s a lot of benefit to be gained with that as well. Self-awareness and stress management – really that was just touching on what I mentioned before about some people having a tendency to carry stress in their pelvic floor and needing to be aware of that. Obviously I would always cover general vulval care advice, point people in the direction of the Vulval Pain Society website and handbook and so on.
Slide 23 (30:53) Musculoskeletal problems
It’s also possible that somebody has coexisting problems with other parts of the musculoskeletal system, and as I mentioned before, this may be other types of chronic pelvic pain, lumbar nerve root compression, trigger points in other muscles, sacroiliac joint dysfunction, sacral torsions – there’s a whole host of other conditions that can occur side by side with vulval pain conditions, and the great thing is that a Women’s Health physiotherapist hopefully should be skilled and experienced in treating all of these conditions. It’s not usually that you would have to see a whole bunch of different physios to get this tackled, although you will usually find that Women’s Health physios do work closely with other specialties, musculoskeletal physiotherapists and the pain specialist physios as well, so there usually is scope for referral across disciplines if it’s necessary.
Slide 24 (31:48) Bladder and bowel problems
Again, this has been mentioned before, but we do also find that there is a common existence of bladder and bowel problems that we do see alongside vulval pain. Physio is able to help with the management of all of these conditions as well, whether it’s painful bladder, overactive bladder, irritable bowel syndrome, chronic constipation, a whole host of things that physio is in a really good position to be able to treat as well.
Slide 25 (32:13) Physiotherapy for vulval pain: does it work?
So, just very quickly: does it work? Because I think you’re probably very interested in that.
Slide 26 (32:19) Does physiotherapy work?
There is gathering evidence, and increasing evidence all the time about the effectiveness of physio. The effectiveness of EMG biofeedback has been very widely documented, particularly by Howard Glazer, who’s a chap who’s based out in the States – some of you may have even made the trip over to see him. That’s where a lot of this work started, actually, it was looking at the effectiveness of biofeedback into pelvic floor rehabilitation. I feel quite strongly that physiotherapy is more than just biofeedback: it’s often a big part of what we do with you, but as you’ve hopefully gathered from the other things that I’ve talked about, there is an awful lot more that we can do that can benefit when you’ve got vulval pain. In terms of some studies that have been done in the not too distant past, there’s been a couple quite recently that have been published that have shown benefit. They’re quite small studies. My study that I’ve mentioned there was a pilot study – as I said before, it was part of my Master’s research, so very small scale, but showed really encouraging results in terms of the effectiveness of a physio approach to treating vulval pain.
Slide 27 (33:29) Does physiotherapy work? (continued)
There are more and more studies coming out which are showing the additive effect of combining biofeedback with other methods. This is what I alluded to when I said I feel like physiotherapy is more than just biofeedback, and in fact the research is starting to show that as well, that a combined approach is the most effective way to treat these kinds of pain syndromes. So, it may be that that includes some CBT, some psychosexual counselling, obviously working alongside your gynaecologist for topical creams or medications if those are indicated. But as I said, most papers to date are small scale, and they’re not generalisable, but I think it’s a good start in terms of showing the effectiveness anyway.
Slide 28 (34:13) Conclusion
Conclusion? There is a wide and diverse role for physiotherapy in treating vulval pain. We are able to offer a multifaceted assessment and treatment approach to vulval pain and the coexisting or contributing factors. The effectiveness is beginning to be shown and recognised. The research and the media interest is increasing and we’ve heard Channel 4 are interested, which is fantastic, but there is limited availability of treatment with specialist physiotherapists, and I will acknowledge that – we’re trying to do something about it in terms of the courses that are available and the training that’s available. But in terms of finding a Women’s Health Physiotherapist, I have just included the ACPWH website on the slide there. You can email somebody through the website who will provide you with a list of Women’s Health physiotherapists in your area. It may be that not all of those Women’s Health physiotherapists have experience in treating vulval pain, but hopefully they’ll be able to put you in touch with somebody who does, because we’re quite a small network, and most of us have got links elsewhere in the country, so we’re often able to direct patients accordingly.
Slide 29 (35:23) Thank you!