Physical Therapy

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Physical therapy can be extremely important in treating pudendal neuralgia. The difficult part is trying to find a physical therapist who has knowledge and experience treating patients with pudendal neuropathy.

For PNE patients, one thing to avoid with physical therapy is kegal exercises. With kegals, you work on strengthening the pelvic floor, but if you have pudendal neuralgia, your pelvic floor is already tight and the Kegal exercises would make them even tighter. Kegal exercises should be avoided until most of the PN symptoms have disappeared. You can start to work yourself up slowly with the Kegal exercises, once the pain has dissipated.

There are a few goals when treating PN with physical therapy. You need to find a pelvic floor physical therapist who does both internal and external work. Some of the goals in physical therapy include:

1. Eradicate myofascial trigger points - The term "trigger point" was coined by Dr Janet Travell (1942) to describe a clinical finding with the following chacteristics:

 

Pain related to a discrete, irritable point in skeletal muscle or fascia, not caused by acute local trauma, inflammation, degeneration, neoplasm or infection. The painful point can be felt as a tumor or band in the muscle, and a twitch response can be elicited on stimulation of the trigger point. Palpation of the trigger point reproduces the patient's complaint of pain, and the pain radiates in a distribution typical of the specific muscle harboring the trigger point. The pain cannot be explained by findings on neurological examination.

 

What is a Fascia: Fascia (from latin: a band) is the soft tissue component of the connective tissue system that permeates the human body. It interpenetrates and surrounds muscles, bones, organs, nerves, blood vessels and other structures. Fascia is an uninterrupted, three-dimensional web of tissue that extends from head to toe, from front to back, from interior to exterior. It is responsible for maintaining structural integrity; for providing support and protection; and acts as a shock absorber.

Common Myofascial trigger point sites include the rectus abdominus, adductors, gluteus minimus, medius, and maximus, obturator internus, piriformis, and quadratus lumborum. Physical therapists will utilize various techniques to help with trigger points. They include manual therapy, trigger point injections and dry needling.

Dry needling, is much like acupuncture. The term "dry needling" is purported to describe the technique of using acupuncture needles on trigger points to release tight muscles.

Procedure for dry needling: To perform the technique, select a 32-guage needle, one inch in length. Find the spasm and insert the needle perpendicularly through the subcutaneous tissue until you contact the spasm. You will feel a definite density change. Do not insert the needle into the muscle. Rather, "bounce" the needle on the muscle using wrist action. This is done anywhere from one to three times a second. When the spasm releases, you will feel the release as a "softening." It's unmistakable and often is felt by the patient as well. Immediately withdraw the needle, and gently massage the area to facilitate qi and xue flow. This might be repeated as necessary along the muscle if there are numerous spasms, or in other muscle groups.

2. Lengthening the Pelvic Floor - Most PN patients have an extremely tight pelvic floor. This makes the pelvic floor shorter than normal. The goal is to lengthen the pelvic floor muscles so that the muscles are no longer in a constant state of contraction. A shortened pelvic floor can compress the pudendal nerve. Physical therapy will use internal vaginal and/or rectal manual therapy, trigger point injections and myofascial release to help lengthen the pelvic floor.

3. Minimize Subcutaneous Panniculosis - This basically means connective tissue restrictions. If the tissues are restricted there will be a decrease in blood flow, muscle atrophy, and thickening of the subcutaneous tissue. Physical therapists will utilize a technique called connective tissue manipulation (CTM) and is performed with minimal pressure as the therapist pushes through the subcutaneous tissue. The goal of CTM is to restore connective tissue integrity, improve circulation and decrease general water retention.

4. Reduce adverse neural tension - Occasionally, the path a nerve takes through the body is narrowed or impinged. This disrupts its normally smooth movement. Typically this occurs as the nerve passes through a muscle or around a bone. Symptoms, such as tingling and numbness, often arise further along the path of the nerve.

Neural tension is defined as an abnormal physiological and mechanical response produced from nervous system structures when their normal range of movement and stretch capabilities are tested. Tight muscles, connective tissue restrictions, and anatomical narrowing of spaces such as Alcock's canal can contribute to neural tension. Manual therapy techniques termed "neural mobilizations" are used to free restricted spaces and restore mobility to peripheral nerves.

Physical therapists will use nerve glides and connective tissue manipulation to lessen the constriction and give more space for the nerve, so it is no longer impinged. Other modalities used are ultrasound. Ultrasound: uses sound waves and may be used to decrease scar tissue, increase blood flow, or decrease pain. Also acupuncture may be of help, as acupuncture uses small, solid needles to encourage healing, reduce pain, and improve function of affected areas of the body.

5. Mobilize connective restricted tissue - With pudendal neuralgia, the nerves can "cross talk" with other nerves, thus sending signals to other nerves in other parts of the body. Sometimes muscles in other areas of the body may become affected and show hyper tonicity. Other areas that could be affected are the lower abdomen, low back, lower extremities and the gluteal region. Physical therapy can help to release some of the muscular tension in these regions. Some techniques used to treat this would be connective tissue manipulation and dry needling.

6. Normalize structure and mechanics - Sometimes, people with pudendal neuralgia can also have structural issues, such as SIJD,( Sacroiliac Joint Dysfunction) pelvic obliquity, issues with core strength and neuromuscular control, and hip mechanics.

What is SIJD? - The sacroiliac joint lies next to the spine and connects the sacrum (the triangular bone at the bottom of the spine) with the pelvis (iliac crest). The joint:

· Is small and very strong

· Transmits all the forces of the upper body to the pelvis (hips) and le

· Acts as a shock-absorbing structure

· Does not have much motion

While it is not clear how the pain is caused, it is thought that an alteration in the normal joint motion may be the culprit that causes sacroiliac joint pain. In the case of sacro-iliac joint dysfunction, abnormal joint positions such as aninnominate rotations will result in increased tension on the ligaments through which the pudendal nerve passes. As a result, the ligaments may compress or shear the nerve and lead to inflammation.

 

What is Pelvic Obliquity? - Pelvic obliquity is the failure of the pelvis to lie in a perfectly horizontal position in the frontal plane. It is a progressive condition and in severe cases can lead to the dislocation of the hip joint and, due to sitting imbalance, to decubitus. Treatment involves manual therapy techniques to correct joint deviation and a home exercise program to strengthen and re-educate the muscles to maintain proper joint position and stability. Prolotherapy is sometimes also used to treat SIJD. Also used are stabilization belts, exercises and orthotic devices, to help correct structural problems. Other techniques utilized by physical therapists that may help to treat pudendal neuralgia are biofeedback, exercises and looking at ways to facilitate muscle relaxation.

Do you need to find a Physical Therapist in your area? Please go to our physical therapy page to find a pelvic floor physical therapist near you. Physical Therapist Page.

There is a wonderful web site called the American Physical Therapy Association. If you cannot find a physical therapist in your area with our Physical Therapy Page, try this web site to find certified physical therapists in your area. You can look under the "Women's Health Section". American Physical Therapy Association

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