Pelvic floor dysfunction (PFD) is a common and relevant condition that affects many patients worldwide. According to our evidence, PFD can affect approximately 20-25% of women and men in the United States,1 contributing to decreased participation in preferred daily, work and recreational activities due to high incidences of lumbopelvic pain, abdominopelvic pain, incontinence, prolapse and/or other urologic and urogynecologic symptoms.2 These symptoms have been shown to have a significant impact on a person’s quality of life and mental health status.2
While PFD is common, the general public has not been fully educated that these dysfunctions are not normal. As clinicians, we have a duty to educate our patient population that PFD is not a normal, nor acceptable, part of the aging process, post-procedural process or postpartum experience. These dysfunctions are both common and very debilitating, but are also very treatable.
Common, not normal. Common, but treatable.
Pelvic floor pathology comes to us as clinicians in a variety of diagnoses, etiologies, and presentations.2 Patients are often referred to physical therapy with medical diagnoses such as: chronic pelvic pain syndrome (CPPS), interstitial cystitis, irritable bowel syndrome, endometriosis, dyspareunia, pudendal neuralgia, bowel and urinary incontinence, and chronic prostatitis.3-5 Symptom presentation is quite varied, but often will include some form of bowel, bladder and sexual dysfunctions and may also include variability in pain presentations. That being said, a multidisciplinary approach is crucial to tailor treatment specific to each patient’s pathology, symptomatology, and clinical presentation.6 Many of these patients have seen a variety of gynecologists, urologists, and gastroenterologists without successful symptom mitigation and are being referred to pelvic health practitioners as a last resort. This is unfortunate, as a primary contributor to these symptoms is the neuromusculoskeletal system…and who better to treat the neuromusculoskeletal system than rehabilitative clinicians?! As part of the multidisciplinary model, rehabilitation clinicians should be included in the first line of defense for treatment intervention.
Multimodal practice is key.
In addition to a multidisciplinary model, a well-rounded, multimodal treatment approach that is tailored to meet the patient’s specific goals is an important step in successfully treating PFD. Patient education can be a very powerful modality, which many clinicians tend to overlook. Research suggests education may help to address central nervous system upregulation, and may help to retrain the brain in how it is processing input.7,8 While it is incredibly powerful to be able to influence pain processing, it doesn’t stop with education. As clinicians, we also need to provide input directly to the involved tissues, especially to the tissues that are the primary, sometimes underlying, driver to the symptom presentation.
Manual therapies may help to desensitize the peripheral nervous system and surrounding soft tissues by providing neural input to alter the source of the pain and disruption.9,10 These techniques, including joint mobilization, soft tissue release, myofascial techniques, tool assisted therapies, or any other manual approach, are likely addressing local tissue issues that may be perpetuating chronic pain or tissue dysfunction.
Dry needling is another effective and efficient technique that pelvic health practitioners can utilize to modulate the central nervous system, peripheral nervous systems and local tissues, including the pelvic floor directly.10 Dry needling encompasses the insertion of solid filament, non-injectate needles into, alongside or around muscles, nerves or connective tissues with or without mechanical and/or electrical stimulation for the management of pain and dysfunction in neuromusculoskeletal conditions.
While the detailed mechanisms of dry needling are not well known, we have seen a growing body of evidence that has provided us with an understanding on how to best utilize this technique in our clinical practice. Overall, it is thought that dry needling may address hypersensitive neural structures and spinal segments,5 enhance treatment of myofascial pain and trigger points in the pelvic floor and surrounding musculature, and assist in the facilitation and/or inhibition of abnormal muscle tone and motor recruitment patterns.10-23 Dry needling has the ability to assist in addressing bladder, bowel and sexual dysfunction alongside addressing pain syndromes in our patient population that is impacted by PFD.
Dry needling is one of the most effective tools we have as rehabilitative practitioners to reset a dysfunctional tissue, providing effective and efficient functional changes for our patients. Ultimately, we are able to facilitate a more balanced resting tone, healthy motor recruitment patterns and optimal neuromuscular utility to re-establish ideal function in our patients. The power of the tissue reset that dry needling provides has changed clinical outcomes for the better and has also positively impacted and changed the lives of many of my clients. Want to add this tool to your clinical practice? Check out our course offerings with the APTA Academy of Pelvic Health!
- Hallock JK. The epidemiology of pelvic floor disorders and childbirth: an update. Obstet Gynecol Clin North Am. 2016 March;43(1):1-13
- Messelink et al. Standardization of terminology of pelvic floor muscle function and dysfunction: Report from the pelvic floor clinical assessment group of the International Continence Society. Neurology and Urodynamics. 2005;24:374-380
- Anderson R, Sawyer T, Wise D, et al. Painful myofascial trigger points and pain sites in men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome. The Journal of Urology. 2009;182:2753-2758
- Hahn L. Chronic Pelvic Pain in Women. Lakartidningen. 2001;98:1780-5
- Kotarinos R. Myofascial Pelvic Pain. Curr Pain Headache Rep. 2012;16:433.438
- Srinivasan A, Kaye J, Moldwin R. Myofascial dysfunction associated with chronic pelvic floor pain: Management strategies. Current Pain and Headache Reports. 2007;11:359-364
- Moseley G. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI evaluation of a single patient with chronic low back pain. Australian Journal of Physiotherapy. 2005;51(1):49-52
- Moseley G. A pain neuromatrix approach to patients with chronic pain. Manual Therapy. Aug 2003;8(3):130-140
- Baron R, Hans G, Dickenson AH. Peripheral Input and Its Importance for Central Sensitization. Ann Neurol. 2013;74(5):630-6
- Chou L, Kao M, Lin J. Probably mechanisms of needling therapies for myofascial pain control. Evidence-Based Complimentary and Alternative Medicine. 2012;705327
- Chen J, Chen S, Kuan T, et al. Phentolamine effect on the spontaneous electrical activity of active loci in a myofascial trigger spot of rabbit skeletal muscle. Archives of Physical Medicine and Rehabilitation. 1998;79(7):790-4
- Cummings T and White A. Needling therapies in the management of myofascial trigger point pain: A systematic review. Archives of Physical Medicine and Rehabilitation. 2001;82(7):986-992
- Gerber L, Shah J, Rosenberger W, et al. Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain. Physical Medicine and Rehabilitation. 2015;7(7):711-718
- Gunn C, Milbrandt W, Little A, et al. Dry needling of muscle motor points for chronic low back pain: A randomized clinical trial with long-term follow-up. Spine. 1980;5(3):279-291
- Hsieh YL, Kao MJ, Kuan TS, et al. Dry needling to a key myofascial trigger point may reduce the irritability of satellite MTrPs. American Journal of Physical Medicine and Rehabilitation. 2007;86(5):397-403
- Lewit K. The Needle Effect in the Relief of Myofascial Pain. Pain. 1979;6(1):83-90
- Shah J. Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis. Journal of Musculoskeletal Pain. 2008;16(1-2):17-20
- Shah J, Danoff J, Desai M, et al. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Archives of Physical Medicine and Rehabilitation. 2008;89(1):16-23
- Sterling M, Valentin S, Vicenzino B, et al. Dry needling and exercise for chronic whiplash: A randomized controlled trial. BMC Musculskeletal Disorders. 2009;10:160
- Tough E, White A, Cummings T, et al. Acupuncture and dry needling in the management of myofascial trigger points: A systematic review and meta-analysis of randomized controlled trials. European Journal of Pain. 2009;13(1):3-10
- Tuzun E, Gildir S, Angın E, et al. Effectiveness of dry needling versus a classical physiotherapy program in patients with chronic low b ack pain: A single-bling, randomized controlled trial. Journal of Physical Therapy Science. 2017;29(9):1502-1509
- Hong C and Torigoe Y. Electrophysiological characteristics of localized twitch responses in responsive taut bands of rabbit skeletal muscle fibers. Journal of Musculoskeletal Pain.1994;2(2):17-43
- Puentedura E, Buckingham S, Morton D, et al. Immediate changes in resting and contracted thickness of transverse abdominis after dry needling of lumbar multifidus in healthy participants: A randomized controlled crossover trial. Journal of Manipulative and Physiological Therapeutics. 2017;40(8):615-623
Authors: Kelly Sammis, PT, DPT, OCS, CLT, A-FDNS, PCES and Tina Anderson, PT, A-FDNS