Transcript of VPS Podcast 4 - Physiotherapy treatment for vulval pain: a presentation given by Helen Forth

Slide 5 (04:15)    Why treat vulval pain with Physiotherapy?

Why treat vulval pain with physiotherapy? At the Royal Free, I have to say that our approach has come as a result of more than ten years of really close collaboration between us as Women’s Health Physiotherapists and our consultants, who we work very closely with. We found anecdotally that we were getting very good results from the approach that we were using in terms of treating women with vulval pain. That actually from a personal point of view led me to conduct my Master’s thesis: my research for my Master’s dissertation was actually looking at the effectiveness of physio treatment for vulval pain, really because we wanted to be able to justify what we were doing and to be able to back up what we thought we knew, which was that it can be very effective for some women.

Why else might physiotherapy be relevant? Well, there’s been a lot of papers in the last few years which have shown us that pelvic floor muscle hypertonicity (and what that means is overactivity), or too much tone in the pelvic floor, can often be found in women who’ve got vulval pain, and that can be found both digitally, so when you’re examined with a digit, i.e. finger, and also on EMG, and I’ll talk a little bit about EMG in a moment. Poor pelvic floor muscle control, lower strength and endurance is often also noted. Why would you have weak muscles if they’re overactive? It sounds a little bit like those two things ought not to go together, but in fact when you’ve got high muscle resting tone, it’s then very difficult to use a muscle effectively and to its full ability. It’s a bit like starting from here and trying to contract your arm further – it’s not as easy as if you’ve got the full range of movement there available to you. Also, specific pelvic floor muscle myofascial trigger points, which Brent [Brent Osborn-Smith, who spoke earlier on osteopathy and acupuncture at the VPS Super Workshop 2010] also touched on, may be found, as may reduced circulation and mobility of the tissues, and that’s something that physiotherapy can help with as well. I’ve put a few references in there. When this presentation gets put on the website, I’ll produce a proper reference list for you, so that if anybody wants to actually go away and look at any of these studies, then you can.

[Editor's note: a full list of references for the papers cited in this presentation is now available at References for VPS Podcast 4 - Physiotherapy for vulval pain: a presentation given by Helen Forth.]

Slide 6 (06:30)    The pelvic floor muscles (diagram)

I just thought it was worth including a couple of slides of the pelvic floor muscles, really just to orientate you and help you to understand why they’re so relevant. I’m not going to talk much about them, but I’m hoping that you can see fairly clearly. The muscle that we’re particularly interested in is labelled there at the bottom of the slide – you can see puborectalis, iliococcygeus are part of the pelvic floor, and are often the muscles where these trigger points that we’ve talked about can be found. The pelvic floor is a big group of muscles: it runs all the way from the pubic bone at the front of the pelvis, and then attaches onto the bottom of the spine, so the sacrum and the coccyx.

Slide 7 (07:11)    The pelvic floor muscles (continued)

It also spans the whole width of the pelvis as well, so it’s not just a small muscle surrounding the vagina, it spans all the way out, covering a big distance, forming a bowl shape – some people like to describe it as a ‘hammock’ – I’m not sure that those descriptions work, actually, because it’s not perhaps quite as round as that alludes to, but gives you the idea that it provides support to the pelvic organs anyway.

Slide 8 (07:38)    The role of the Physiotherapist in treating vulval pain

The role of a physiotherapist in treating vulval pain: I’ve actually taken this from a study published by somebody called Sophie Bergeron, who’s quite a prominent researcher in this field. She’s based out in Canada, and she tells us that the role of the physiotherapist in treating vulval pain should be to increase pelvic floor muscle awareness and proprioception, to improve pelvic floor muscle strength, speed, endurance and muscle discrimination, so that just means your ability to isolate your pelvic floor muscles, to reduce pelvic floor muscle hypertonicity, so that’s the overactivity or the increase in tension that I mentioned, and to improve voluntary relaxation of the pelvic floor. It’s also to improve elasticity of the tissues at the vaginal opening and to reduce fear of vaginal penetration. I’ve also added counselling skills to the bottom of that list because I do think that that’s a very important aspect of the physiotherapist’s role. All physiotherapists are trained to listen, and that’s all that counselling means, if you take it right back. I’m not saying that physiotherapy can take the place of psychosexual counselling, or formal counselling, if that’s indicated, but really just to say that there is a counselling benefit there through seeing a physiotherapist, and being listened to, and I think you’ve heard that actually from all of us, that that’s a very important aspect of what as professionals we should be doing for you.