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

Slide 11 (15:05)    Pelvic floor muscle rehabilitation: Myofascial trigger point release

OK, so just a little bit more about trigger points… I’ve just included a definition here, which is that myofascial trigger points, so that basically just means trigger points within muscle, are ‘hyperirritable spots in skeletal muscle associated with a hypersensitive palpable nodule’, so you can actually feel them, ‘in a taut band’ of muscle. That trigger point tends to be painful on palpation, and it’s worth saying that myofascial trigger points often refer and reproduce pain when palpated. I can’t remember who said it already this morning, but somebody did, that often when you press on a trigger point, a patient will say: ‘That’s my pain’, so you know that that’s the spot. Not only can you as a therapist feel it, but the patient knows that that’s reproducing their symptoms. We know that myofascial trigger points are really common in the pelvic floor muscles in women who’ve got any type of chronic pelvic pain, not just vulval pain actually, but other types as well. Myofascial trigger points can be released manually, by the treating physiotherapist, or osteopath, or whoever you’re seeing, and also by the patient themselves at home. And actually, it’s one of the things we often do, is teach patients how to do trigger point release themselves so that they get some lasting benefit from the therapy that we do with them in clinic. If you can release off trigger points, effectively that will often lead to a reduction in this level of resting tone within the pelvic floor.

Slide 12 (16:32)    Pelvic floor muscle: myofascial trigger points

I’ve just included a picture – just a couple of examples of where there might be trigger points within the pelvic floor. I’m actually most interested, and I think you’ll be most interested, in this picture up here. [She indicates the slide, which shows the referral pattern of pelvic floor muscle trigger points in the external anal sphincter and coccygeus muscles.] These crosses are areas where it’s quite common to find trigger points within the pelvic floor, and as far as the referral pattern for those trigger points is concerned, it can be in this region. There are other trigger points in surrounding areas that can be very relevant as well, but these are particularly significant in terms of looking at pelvic floor activity.

Slide 13 (17:09)    Pelvic floor muscle: myofascial trigger points – self help

From a self-help point of view with trigger points, I would say that trigger point release should really be done with teaching and guidance from a physiotherapist – again, it’s not something to go away and just have a go at. But self-release can be really effective. It’s really important, I feel, to do this within the limits of your pain. You don’t want to be doing something that’s going to cause you so much pain that it sort of sets up that vicious cycle of expectation and oversensitivity, and thinking that it’s always got to be painful to insert something into the vagina, which it doesn’t always have to be. I think trying to do this sort of self-help stuff within the limits of what you’re able to cope with and manage is actually really important from that point of view. Generally, women find it easier to do self trigger point release in their pelvic floor using their thumb: it’s just easier to reach for most people, although there are some quite deep trigger points that you may not be able to get to with your thumb, and you might need to find a way to get your index finger to reach. It’s quite tricky: you do have to be quite mobile and dextrous to be able to do it, and that’s why it’s quite important to try and do it under the guidance and the supervision of a physiotherapist. When you’re releasing a trigger point, you only normally need to apply pressure for somewhere between one and two minutes. You should find that if you’ve hit the spot, pain will decrease and the muscle will release. That’s basics, anyway, in terms of how trigger point release might work.

Slide 14 (18:44)    Biofeedback

Something you might be even more keen to hear about is biofeedback. It’s become really popular, and there’s been some really good work done looking at its effectiveness. I have again just included a definition and a basic overview of what it means. It is a method of measuring a biological process, actually any type of biological process, but examples might be heart rate, or muscle tension, and feeding this signal back to the patient, through the use of either a visual or a sound signal. You’ll see when I get some of the bits of equipment out, that some of the biofeedback that we do as physiotherapists might involve a probe that’s inserted into the vagina that’s attached to either, if you’re in a clinic, a computer with a screen, where you get graphs on the screen that show you what’s going on with your pelvic floor, or it might be a little hand-held unit that’s got lights that light up, or sounds, or beeps that go off, that show you how strongly you’re contracting your muscles, or how well you’re relaxing them, and that extra feedback is a really good way of helping you to learn how to effectively use your pelvic floor. It’s just an additional method, really, of reinforcing what it is we’re trying to get you to learn from that point of view. The level of the signal reflects the intensity of the biological function, which in this case is the muscle activity. The idea is that to alleviate symptoms, you as a patient are trying to take some control over this biological process. The most commonly used form of biofeedback for vulval pain would be EMG biofeedback of the pelvic floor muscles.