Trigger Point Treatment in Chronic Pelvic Pain
Condition: Chronic Pelvic Pain Syndrome; Myofascial Trigger Point Pain
MeSH terms: Myofascial Pain Syndromes; Pelvic Pain
Study type: Interventional

Summary: 
      Objective: To investigate the effectiveness of ischemic compression and low-level laser
      therapy methods combined with exercise on the myofascial trigger points in women with Chronic
      Pelvic Pain and to determine which method is more effective.

      Methods: It was a parallel designed, single-blind pilot randomized clinical trial. Patients
      were enrolled in the Department of Obstetrics and Gynecology (at Istanbul
      University-Cerrahpasa). The patients were diagnosed by a gynecologist (F.G.U and C. Y.),
      referred to the clinical laboratory of physiotherapy and rehabilitation to participate (by
      physiotherapists K.S. and E.K.M.) in the trial from September 2017 to June 2019. Twenty-eight
      women patients with Chronic Pelvic Pain were included into the trial. Patients were
      randomized into two groups. Group 1 received ischemic compression and Group 2 received
      low-level laser therapy twice a week for 6 weeks. Both groups received the same standard
      exercise program. Pain, range of motion, pelvic floor symptom severity, quality of life,
      satisfaction, anxiety, and depression were assessed after 6 weeks and 1-year follow up.
    

Detailed description: 
      Chronic pelvic pain (CPP) is chronic or persistent pain perceived in structures related to
      the pelvic region. CPP prevalence range between 5.7 % and 26.6 % in women. CPP is associated
      with symptoms suggestive of the lower urinary tract, sexual, bowel, pelvic floor, or
      gynecological dysfunction. It is often associated with negative emotional consequences and
      impaired quality of life (QoL) Analgesics, hormone therapy, physiotherapy, psychological
      treatment, and surgical methods are widely used in the treatment of CPP. Medications provide
      pain and visceral management, surgery provides correction of structure, but physiotherapy
      approachs provides functional restoration. Musculoskeletal pelvic pain is commonly originated
      myofascial, musculoskeletal, neuromuscular structures. CPP patients have myofascial trigger
      points (MTrPs) located in the lower back, abdominal wall, and pelvic girdle, which may be the
      primary source of pain. These MTrPs are usually located in levator ani, obturator internus,
      piriformis, gluteal muscles, quadratus lumborum and abdominal wall muscles. The MTrPs are
      hyperirritable spots within a taut band, activated by repeated or chronic muscular overload.

      Ischemic compression (IC), in the other words trigger point compression, is an effective
      method in the treatment of MTrPs in many musculoskeletal problems. IC changes the circulatory
      perfusion of skin and is especially valuable in muscles that are not suitable for stretch. It
      is less common to use pelvic floor rehabilitation, urological CPP, interstitial cystitis and
      painful bladder syndrome and CPP yet. Low-level laser therapy (LLLT) reduces pain in MTrPs
      lead to musculoskeletal system disorders. LLLT increases oxygen supply to hypoxic cells in
      MTrPs areas by regulating microcirculation as well as it has analgesic, biostimulation, and
      wound healing effects . In the literature, it is seen that IC and LLLT are effective on
      MTrPs, and IC is used in pelvic pain in a few studies. But the use of LLLT in pelvic pain has
      not been found. It is a known fact that exercise is the basis for these MTrPs treatments. In
      light of this knowledge, investigetors hypothesized that both IC and LLLT combined with
      exercise would be an effective methods in the management of CPP.
    

Intervention name(s): Ischemic compression; Low-level laser therapy; Standardized exercise program
Intervention type(s): Other; Device; Behavioral
Intervention description(s): IC was applied over the detected MTrPs and the participant was asked to describe the pressure and pain she felt . It was started with moderate tolerable pressure (7/10) and then severity was increased. The color of the thumb pulp was observed to control the pressure. The pressure was continued for 90 sec. The patient's pain sensation continued to be questioned and the pressure was controlled to a level at "comfortable pain"; LLLT was applied for 90 sec at each MTrPs with a frequency of 2000 Hz (3 J) using a GaAs diode laser instrument (Roland Serie Elettronica Pagani, wavelength 904 nm, the frequency range of 5-7000 Hz and maximum peak power of 27, 50 or 2764 W) . The laser probe was held perpendicular to the MTrPs in skin contact without pressure.; The standardized exercise program included stretching and pilates exercises for core stabilization. All exercises were supervised by the same physiotherapist whom certificated by The Australian Physiotherapy and Pilates Institute (APPI). Pilates exercises were selected from APPI's mat-work exercises and performed in accordance with APPI principles. In addition, patients performed stretching exercises for 5 days a week and pilates exercises for 3 days a week at home.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Randomized parallel designed two arm clinical study
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment