A directional preference approach for chronic pelvic pain, bladder dysfunction and concurrent musculoskeletal symptoms: a case series

ABSTRACT

Background

Chronic pelvic pain (CPP) with concurrent musculoskeletal and bladder symptoms is a complex and challenging problem. However, clinically the co-existence of these symptoms is not routinely questioned, and their musculoskeletal source is not investigated thoroughly. The purpose of this case series is to present the use of Mechanical Diagnosis and Therapy (MDT) principles in seven patients with concurrent chronic pelvic pain, bladder dysfunction and musculoskeletal symptoms.

Case Descriptions

Seven patients with coexisting pelvic health and musculoskeletal signs and symptoms were retrospectively reviewed. Most common symptoms were urinary frequency, incontinence, pelvic pain, nocturia, dyspareunia, bladder dyssynergia, and lumbar, pelvic or hip pain. All patients failed to recognize the possible interconnectedness of the two sets of symptoms. Each exhibited a directional preference (DP) and subsequent MDT provisional classification of derangement was established; the use of DP forces abolished or dramatically improved both symptoms and mobility impairments. In all cases DP was for sustained sagittal forces initially, but ultimately lateral forces and mobilization were indicated.

Outcomes

Changes in Pelvic Floor Impact Questionnaire, Care Connections Pelvic Floor and Lumbar spine were all clinically significant and exceeded minimally Clinical Important Differences several times. Average of 5.8 sessions per patient was noted. Follow-up at an average of 3.3 years revealed ongoing satisfaction and confidence in independent self-management.

Discussion

These case studies highlight the importance of ensuring expansion of intake questions for possible co-existence of symptoms in both pelvic and musculoskeletal patients, possibly suggesting a mechanical intervention is indicated. Provisional subclassification into ‘Mechanical Pelvic Syndrome’ is proposed.

Level of Evidence: 4.

KEYWORDS:

• Directional preference
• thoracolumbar
• pelvic pain
• incontinence
• low back pain
• dyspareunia
• hip pain
• urinary frequency
• spinal mobility loss
• bladder dyssynergia
• mechanical diagnosis and therapy
• mobilization

Contributors

Only the authors listed contributed to the paper, there were no additional contributors.

Disclosure statement

No potential conflict of interest was reported by the authors.

Supplementary material

Supplemental data for this article can be accessed here.

Ethics approval

IRB approval gained from Providence Health and Services (Oregon) IBD ID 2,019,000,384. The subjects gave written informed consent.

Additional information

Funding

There is no financial support to declare.

Notes on contributors

Christine Hughes

Christine Hughes graduated in 1984, has since then has focused on the care of both the orthopedic and pelvic health population. She has assisted in APTA sponsored pelvic health courses has taught multiple community courses for the pre- natal and post-partum population. She recently presented this case series as a poster presentation at the MDT Conference of America in 2016.

Stephen May

Stephen May trained as a physiotherapist in Leeds, UK, and graduated in 1990; and then worked in the NHS musculoskeletal care in the UK, mostly in primary care. He then became a senior lecturer and Reader at Sheffield Hallam University. He has written a number of text books, especially with Robin McKenzie, chapters in text books, and numerous articles in scientific journals; with approaching 100 publications in total.