Treatment of Women in the United States with ...

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78. Suggestion of dietary changes. 77. Instruction/help with sexual function. 68. Instruction in use of vaginal dilators. 67. Surface electromyogram (non-Glazer.
Reprinted with permission from Hartman D, Strauhal MJ, Nelson CA. Treatment of women in the United States with localized provoked vulvodynia. J Reprod Med. 2007;52:48–52. The Journal of Reproductive Medicine®

Treatment of Women in the United States with Localized, Provoked Vulvodynia Practice Survey of Women’s Health Physical Therapists Dee Hartmann, P.T., M. J. Strauhal, P.T., and Carlotta A. Nelson, M.B.A., M.P.H.

with contact irritants, dietary changes and sexual funcOBJECTIVE: To identify current practice trends of tion. Typical care is 60-minute weekly sessions for 7–15 physical therapists in the U.S. treating women with loweeks. calized, provoked vulvodynia (LPV). CONCLUSION: Sixty-three STUDY DESIGN: The Secpercent of physical therapists tion on Women’s Health conOur goal in creating and conducting in the U.S. treating women ducted an Internet poll in with LPV have > 11 years of July of 2005 inquiring about the survey was to come to a experience, with almost half physical therapy care of women diagnosed with LPV. It consensus on what the best practices treating women for > 6 years. Obstetrician/gynecologists are queried clinicians’ demofor physical therapy should be for the largest referral source. graphics, physician/clinician women with this diagnosis. Three quarters agree on 14 referral patterns, assessment/ assessment tools, while more treatment modalities and than two thirds agree on 11 treatments. Women are length of care. treated weekly for 1 hour, for 7–15 weeks. (J Reprod RESULTS: Nearly two-thirds reported > 11 years of Med 2007;52:48–52) physical therapy experience, with 42% treating women with vulvodynia for > 6 years. Most referrals were from Keywords: vulvar diseases, physical therapy (speobstetrician/gynecologists. Assessment modalities used by > 70% included detailed history; assessment of poscialty), vulvodynia. ture, tension in the pelvic floor, pelvic girdle, associated Much has been written in recent years regarding the pelvic structures and bowel/bladder function; digital sEMG/pEMG testing of the pelvic floor; hip, sacroiliac appropriate nomenclature for vulvodynia. The most recent terminology, accepted in 2003 by the joints and spine mobility; strength testing of abdominals and lower extremities; and voiding diaries. Nearly 70% International Society for the Study of Vulvovaginal Disease (ISSVD), recognizes the symptoms of vulutilized exercise for the pelvic girdle and pelvic floor; soft tissue mobilization/myofascial release of the pelvic girdle, vodynia as “vulvar discomfort, most often described as burning pain, occurring in the absence of pelvic floor and associated structures; joint mobilizarelevant visible findings or a specific, clinically tion/manipulation; bowel/bladder retraining and help From Dee Hartmann Physical Therapy for Women, Chicago, Illinois; Providence Health System, Portland, Oregon; and Advocate Good Samaritan Hospital, Downers Grove, Illinois. Presented at the XVIIIth World Congress of the International Society for the Study of Vulvovaginal Disease, Queenstown, New Zealand, February 20–24, 2006. Address correspondence to: Dee Hartmann, P.T., 400 East Randolph, Professional Suite 205, Chicago, IL 60601 ([email protected]). Financial Disclosure: The authors have no connection to any companies or products mentioned in this article.

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0024-7758/07/5201-0048/$15.00/0 © Journal of Reproductive Medicine®, Inc. The Journal of Reproductive Medicine®

Journal of Women’s Health Physical Therapy, 31:3, Winter 2007

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identifiable, neurologic disorder.”1 The diagnosis is one of exclusion, when no other identifiable etiology (infection, inflammatory process, neoplasia or neurologic disorder) is present. Further delineation of the disorder is by the location and cause of symptoms. Localization of the pain suggests that the vulvar pain can be either localized (involving only a portion of the vulva) or generalized (involving the vulva as a whole). Provocation of the pain suggests that symptoms can be either provoked (by sexual and/or nonsexual touch) or unprovoked (by sexual and/or nonsexual touch). Before physical therapy treatment outcomes of women with vulvodynia can be validated, assessment and treatment protocols must be established and then tested at multiple sites with effective outcomes tools. With that in mind, the American Physical Therapy Association’s Section on Women’s Health initiated the Vulvar Pain Task Force in February 2003. The task force’s purpose is to: (1) develop evidence-based practice guidelines for physical therapy management of women with chronic vulvar pain; (2) establish a research agenda that addresses pathology/etiology, clinical presentation and validity, reliability, and predictive value of assessment tools; and (3) develop a plan to effectively communicate guidelines and research findings to the physical therapy community and to the public. The goals of the task force, directed toward the above purpose, include: (1) defining and describing vulvar pain in terms of pain, impairment, functional limitations and disabilities; (2) describing the role of physical therapy in the management of women

Table I Percentage of Physical Therapists Receiving Referrals from Various Specialties Specialty Obstetrcian/gynecologists Urologists Urogynecologists Other physical therapists General practitioners Nurse practitioners Internists Psychiatrists Othersa Sex therapists Psychiatrists, counselors aSelf-referrals,

% Of physical therapists receiving referrals 94 59 53 51 41 41 27 17 13 8 5

physician assistants, midwives, dermatologists, chiropractors, colorectal surgeons, naturopathic physicians, oncologists, pain specialists and acupuncturists.

Journal of Women’s Health Physical Therapy, 31:3, Winter 2007

Table II Summary of Duration and Frequency of Physical Therapy Care for Women Diagnosed with LPV Variable Average no. of physical therapy sessions per wk 1 2 3 4 5 >5 Average time spent on initial evaluation (min) 60 90 75 45 > 90 30 Average time spent on treatment (min) 60 45 30 75 ≥ 90 Average no. of physical therapy visits (evaluation through discharge) 7–10 11–15 16–20 4–6 21–25 26–30 1–3 31–40

%

66 30 3 0 21). A large number (79%) of physical therapists referred their patients to other health care and allied health professionals. Of that group, 66% referred their patients to physicians other than the primary referring physician, 53% referred patients to psy-

Journal of Women’s Health Physical Therapy, 31:3, Winter 2007

1. Education on pelvic floor function 2. Manual techniques (myofascial release, trigger point pressures, massage) 3. Surface electromyogram 4. Electrical stimulation 5. Exercise (pelvic floor and use of vaginal dilators)

chotherapists, 48% referred to massage therapists, 38% referred to either acupuncturists or sex therapists, 32% referred to nutritionists, and 18% referred to other physical therapists. Sixteen percent referred to a variety of other professionals, including referral to yoga and naturopathic medicine practitioners and for craniosacral therapy or chiropractic manipulation. Frequency and Duration of Physical Therapy Care Two thirds (66%) of those surveyed treated women with LPV on a weekly basis, with 30% treating twice weekly. Time spent on evaluation was 60 minutes for 64% of those responding. Treatment times varied, though 52% were using 60-minute treatment intervals. The majority of physical therapists (71%) treated this population for a total of 7–15 visits from evaluation through discharge (Table II). Assessment Tools When asked to choose assessment items that are routinely included in evaluation of women with LPV, the respondents showed a high level of agreement: at least 72% were in consensus on the use of 14 assorted assessment tools (Table III). Treatment Modalities The same held when > 66% agreed on 11 modalities that should be included in a treatment protocol for

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women with localized, provoked vulvodynia (Table IV). Outcome Tools When questioned on the use of outcomes measures, 55% reported using tools to measure changes in pain, 48% measure functional outcomes, and 36% measure issues related to quality of life. When measuring changes in pain, the respondents favored use of Visual Analog Scales, the Perceived Pain Index and a modified Oswestry Questionnaire. A portion were using a variety of functional outcomes tools, such as the SF-36 and PatientSpecific Functional Scale. Others reported using tools that were produced individually by the hospital or clinic where they were employed. Discussion Though physical therapy has been cited as an efficacious treatment for women with vulvodynia,3-5 no standardized assessment or treatment protocols have been suggested or studied. Hartmann and Nelson3 detailed assessment tools and treatment modalities for women diagnosed with either dysesthetic vulvodynia (generalized, unprovoked vulvodynia) or vulvar vestibulitis syndrome (LPV), with a mean number of 15 clinical visits for both diagnoses. Bergeron4 cited treatment modalities used in treating women with vulvar vestibulitis syndrome (LPV), with a mean number of physical therapy sessions of 7 (Table V). Though Hartmann suggested that her referral sources were ISSVD members, no specific references were made to demographics of either the treating therapists or of the referring physicians or other clinicians. Though these data

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were published but not validated, they served as this survey’s starting point. The professionals involved with the Vulvar Pain Task Force have joined together, generating an enormous base of knowledge and treatment experience. Our goal in creating and conducting the survey was to come to a consensus on what the best practices for physical therapy should be for women with this diagnosis. The survey’s greatest limitation is that it reached only members of the Section on Women’s Health in the United States. Certainly there are many more clinicians, both in the United States and around the world, who have exceptional experience treating this difficult population of women. Clearly, with the results of the survey, we now have a point from which to advance. References 1. Moyal-Barracco M, Lynch PJ: 2003 ISSVD terminology and classification of vulvodynia: A historical perpective. J Reprod Med 2004;49:772–777 2. American Physical Therapy Association’s Section on Women’s Health Vulvar Pain Task Force: Missions and Purpose Statement. Alexandria, Virginia, APTA, 2005 3. Hartmann EH, Nelson CA: Perceived effectiveness of physical therapy treatment on women with chronic vulvar pain and diagnosed with either vulvar vestibulitis syndrome or dysesthetic vulvodynia. J Section of Women’s Health, APTA 2001;25:13–18 4. Bergeron S, Brown C, Lord MJ, et al: Physical therapy for vulvar vestibulitis syndrome: A retrospective study. J Sex Marital Ther 2002;28:183–192 5. Bergeron S, Lord MJ: The integration of pelvi-perineal reeducation and cognitive-behavioural therapy in the multidisciplinary treatment of the sexual pain disorders. Br Assoc Sex Relationship Ther 2003;18:135–141

Journal of Women’s Health Physical Therapy, 31:3, Winter 2007