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Chronic Pelvic Pain Persisting after Childbirth: Diagnosis and Implications for Treatment
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Objectives: To explore the pain mechanism and the origin of the pain and to evaluate a short-term pain relief treatment in women suffering from CPP persisting after childbirth in order to enable physiotherapeutic intervention.

Material and methods: Thirty-six parous women with chronic pelvic pain persisting after childbirth were recruited at the Department of Physiotherapy, SundsvallHospital and by advertisements in newspapers and 29 parous women without chronic pelvic pain were recruited from an organized gynaecological screening at a midwifery surgery. All women were provoked by intra-pelvic palpation of 13 predetermined intra-pelvic landmarks. The provoked pain distribution was expressed in pain drawings and the pain intensity verbally on a Likert scale.Also, in a randomised controlled trial the 36 women with chronic pelvic pain were allocated to bilateral injection treatment with either triamcinolone or saline solutions, given once on the ischial spine with follow-up after four weeks.

Results: Referred pain provoked on intra-pelvic landmarks follows a specific pattern. In general, pain provoked by palpation of the posterior intra-pelvic landmarks was mostly referred to the sacral region and pain provoked by palpation of the ischial and pubic bones was mostly referred to the groin and pubic regions. In women with chronic pelvic pain the provoked pain distribution area and pain intensity were magnified as compared to women without chronic pelvic pain.

In the clinical trial decreased pain intensity, decreased distribution of pain and improved physical function was achieved among the triamcinolone treatment group as compared to the saline treatment group. Also, a positive correlation was shown between reduced pain intensity and improved function.

Conclusions: Referred pain patterns provoked on intra-pelvic landmarks in women with chronic pelvic pain persisting after childbirth are consistent with sclerotomal sensory innervations and indicates allodynia and central sensitisation. This suggests that pain mapping can be used to evaluate and confirm the pain experience and contribute to diagnosis. Also, the pain intensity provoked by stimulation of the intra-pelvic landmarks is suggested to be useful to differentiate women with chronic pelvic pain from those without. Corticosteroid treatment to the ischial spine resulted in decreased pain and increased function.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2014. , 67 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 958
Keyword [en]
Chronic pelvic pain, corticosteroid, injection, pain mapping, pelvic pain, physical function, physiotherapy, pregnancy, randomised controlled trial, referred pain, sensitisation
National Category
Physiotherapy
Research subject
Physiotherapy
Identifiers
URN: urn:nbn:se:uu:diva-211847ISBN: 978-91-554-8826-0 (print)OAI: oai:DiVA.org:uu-211847DiVA: diva2:677537
Public defence
2014-02-06, Museum Gustavianum Auditorium Minus, Akademigatan 3 753 10 Uppsala, Uppsala, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2014-01-16 Created: 2013-12-02 Last updated: 2014-01-24
List of papers
1. Referred pain patterns provoked on intra-pelvic structures among women with and without chronic pelvic pain: a descriptive study
Open this publication in new window or tab >>Referred pain patterns provoked on intra-pelvic structures among women with and without chronic pelvic pain: a descriptive study
Show others...
2015 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 3, e0119542Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES:

To describe referred pain patterns provoked from intra-pelvic structures in women with chronic pelvic pain (CPP) persisting after childbirth with the purpose to improve diagnostics and give implications for treatment.

MATERIALS AND METHODS:

In this descriptive and comparative study 36 parous women with CPP were recruited from a physiotherapy department waiting list and by advertisements in newspapers. A control group of 29 parous women without CPP was consecutively assessed for eligibility from a midwifery surgery. Inclusion criterion for CPP was: moderate pain in the sacral region persisting at least six months after childbirth confirmed by pelvic pain provocation tests. Exclusion criteria in groups with and without CPP were: persistent back or pelvic pain with onset prior to pregnancy, previous back surgery and positive neurological signs. Pain was provoked by palpation of 13 predetermined intra-pelvic anatomical landmarks. The referred pain distribution was expressed in pain drawings and described in pain maps and calculated referred pain areas.

RESULTS:

Pain provoked by palpation of the posterior intra-pelvic landmarks was mostly referred to the sacral region and pain provoked by palpation of the ischial and pubic bones was mostly referred to the groin and pubic regions, with or without pain referred down the ipsilateral leg. The average pain distribution area provoked by palpation of all 13 anatomical landmarks was 30.3 mm² (19.2 to 53.7) in women with CPP as compared to 3.2 mm² (1.0 to 5.1) in women without CPP, p< 0.0001.

CONCLUSIONS:

Referred pain patterns provoked from intra-pelvic landmarks in women with CPP are consistent with sclerotomal sensory innervation. Magnification of referred pain patterns indicates allodynia and central sensitization. The results suggest that pain mapping can be used to evaluate and confirm the pain experience among women with CPP and contribute to diagnosis.

National Category
Clinical Medicine
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-211840 (URN)10.1371/journal.pone.0119542 (DOI)000352084200093 ()25793999 (PubMedID)
Available from: 2013-12-02 Created: 2013-12-02 Last updated: 2017-12-06Bibliographically approved
2. Provoked pain intensity on intra-pelvic structures in women with and without chronic pelvic pain
Open this publication in new window or tab >>Provoked pain intensity on intra-pelvic structures in women with and without chronic pelvic pain
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Clinical Medicine
Identifiers
urn:nbn:se:uu:diva-211842 (URN)
Available from: 2013-12-02 Created: 2013-12-02 Last updated: 2014-03-21
3. Corticosteroid Injection Treatment to the IschiadicSpine Reduced Pain in Women With Long-LastingSacral Low Back Pain With Onset During Pregnancy: A Randomized, Double Blind, Controlled Trial
Open this publication in new window or tab >>Corticosteroid Injection Treatment to the IschiadicSpine Reduced Pain in Women With Long-LastingSacral Low Back Pain With Onset During Pregnancy: A Randomized, Double Blind, Controlled Trial
2009 (English)In: Spine, ISSN 0362-2436, E-ISSN 1528-1159, Vol. 34, no 21, 2254-2258 p.Article in journal (Refereed) Published
Abstract [en]

Study Design

Randomized double blind controlled clinical trial.Objective. To evaluate the pain relief effect of locally injected corticosteroid treatment in women with long-lasting sacral low back pain with onset during pregnancy.

Summary of Background Data

Pregnancy-related low back pain is a global problem. Almost 1 of 10 women still experienced disabling daily back pain 2 years after childbirth with high impact on the individual, family, and society. In spite of this, the sources of pain and effective treatment are uncertain.

Methods

Thirty-six women were allocated to injectiontreatment, with slow-release triamcinolone and lidocaine or saline and lidocaine, given at the sacrospinous ligament insertion on the ischial spine bilaterally with 4 weeks follow-up time. Primary outcome measure was reported pain intensity on visual analogue scale and secondary outcome measures number of pain-drawing locations and pain-provoking test results.'

Results

The triamcinolone treatment group had significantly reduced pain intensity, number of pain locations,and pain-provoking test results between baseline and follow-up as compared with the saline treatment group. The absolute median change of visual analogue scale score in the triamcinolone treatment group was 24 mm and in the saline group 4.5 mm (P‹0.05). A reducednumber of pain drawing locations was reported by16 of 18 women in the triamcinolone group as compared with 10 of 18 in the saline group (P‹0.05). In the triamcinolone treatment group, 17 of 18 women had an improved pain provocation test result as compared with 9 of 18 in the saline treatment group (P‹0.01).

Conclusion

The anatomic region around the sacrospinousligament insertion on the ischial spine is suggestedto be one source of long-lasting sacral low back pain withonset during pregnancy. The pain was relieved by slowrelease corticosteroid injection treatment to the ischial spine.

Keyword
Pregnancy, pelvic pain, corticosteroid, injections, low back pain
National Category
Physiotherapy Clinical Medicine
Research subject
Physiotherapy
Identifiers
urn:nbn:se:uu:diva-211832 (URN)10.1097/BRS.0b013e3181b07eac (DOI)
Available from: 2013-12-02 Created: 2013-12-02 Last updated: 2017-12-06Bibliographically approved
4. Improved function in women with persistent pregnancy-related pelvic pain after a single corticosteroid injection to the ischiadic spine: a randomized double blind controlled trial
Open this publication in new window or tab >>Improved function in women with persistent pregnancy-related pelvic pain after a single corticosteroid injection to the ischiadic spine: a randomized double blind controlled trial
2013 (English)In: Physiotherapy Theory and Practice, ISSN 0959-3985, E-ISSN 1532-5040, Vol. 29, no 5, 371-378 p.Article in journal (Refereed) Published
Abstract [en]

Background: Pregnancy-related low back and pelvic pain is a worldwide problem. A large proportion of women still experience disabling daily back pain 2 years after childbirth, resulting in major changes in activities and general well-being. In spite of this, the source of pain and effective treatment are uncertain. Objective: To evaluate the short-term effects on function of a single corticosteroid injection treatment to the ischiadic spine in women with persistent pregnancy-related pelvic pain (PPPP). Methods: Thirty-six women were allocated to injection treatment with slow-release triamcinolone and lidocain or saline and lidocain, given once at the sacrospinous ligament insertion on the ischiadic spine bilaterally with follow-up at 4 weeks. Outcome measures were Disability Rating Index (DRI), self-rated functional health (SF-36), gait speed and endurance (6MWT), and strength and endurance of trunk muscles (isometric trunk extensor and flexor tests). Results: Women in the triamcinolone group showed significantly improved DRI (p  =  0.046), 6MWT (p  =  0.016), and isometric trunk extensor tests (p  =  0.004), as compared with the saline group. Close co-variation was shown between improved function and reduced pain intensity. Conclusions: Improved function was achieved among women with PPPP after a single injection treatment with slow-release corticosteroid. The effect was positively correlated to the reduced pain intensity.

National Category
Physiotherapy
Identifiers
urn:nbn:se:uu:diva-191351 (URN)10.3109/09593985.2012.734009 (DOI)000319577000003 ()23713407 (PubMedID)
Available from: 2013-01-10 Created: 2013-01-10 Last updated: 2017-12-06Bibliographically approved

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