Postural changes in women with chronic pelvic pain
From: BMC Musculoskelet Disord. 2009 Jul 7;10(1):82. [Epub ahead of print]
Among women, chronic pelvic pain is a highly prevalent (2% to 25%) clinical problem, with substantial costs as well as social and marital repercussions. Chronic pelvic pain is defined as continuous or recurrent pain in the lower abdomen or pelvis lasting at least six months, not related to pregnancy, and sufficiently severe to interfere with the habitual activities of the patient. Chronic pelvic pain excludes pain occurring exclusively in association with menstruation (dysmenorrhea) or during sexual intercourse (dyspareunia).
Although the etiology is often unknown, it may result from complex interactions among the gastrointestinal, urinary, gynecologic, musculoskeletal, neurologic and endocrine systems, as well as being influenced by psychological and sociocultural factors. To date, few therapeutic modalities have been effective in relieving the symptoms of chronic pelvic pain, particularly over the long term. An interdisciplinary approach has therefore been recommended, both to diagnose the presumed primary etiology, and to diagnose and control all the secondary factors associated with chronic pelvic pain.
In clinical practice, postural changes are frequently observed among women with chronic pelvic pain. Although this disease has been associated with musculoskeletal changes and particular postures, to date there have been no studies of the detailed postural evaluation of women with chronic pelvic pain, which can be performed by attending physicians, especially primary care physicians and gynecologists. Postural assessment can lead to early detection of uneven positions, shortenings, antalgic postures and tensions. Although these changes may not be the primary cause of the clinical condition, they can contribute significantly to the worsening of pain and tension. The authors therefore determined the frequency of postural changes in women with chronic pelvic pain, as assessed only by clinical examinations.
The authors observed statistically significant differences in the cervical spine and scapulae between women with chronic pelvic pain and control women. The authors believe that the changes observed in women with chronic pelvic pain resulted from a vicious cycle of pain and antalgic postures acquired over time. The mean duration of symptoms among women with chronic pelvic pain was about five years, and postural impairments over time can contribute significantly to the maintenance or worsening of pain. Nevertheless, the authors cannot conclude that women with chronic pelvic pain always show the same postural pattern. First, although the authors observed an association between chronic pelvic pain and postural changes, the control group, consisting of women who did not report any type of pain, also presented with several postural changes.
Additionally, the authors believe that postural changes among controls occurred because posture depends not only on pathologic condition, but on several other factors, including habits acquired by individuals throughout life, their work activities, and even their emotional and psychological states. Second, the authors study design did not allow them to determine whether postural changes were the cause or consequence of chronic pelvic pain. However, identifying postural changes is an important part of evaluating women with chronic pelvic pain because improvements in posture can contribute to improvement in chronic pelvic pain symptoms.
In this study, posture was assessed in a strictly clinical manner, with the examiners recording the static posture adopted by the women. This method of assessment was used because the authors wanted to determine the efficacy and reproducibility of this type of evaluation so that it might be incorporated into clinical practice in the evaluation of women with chronic pelvic pain. Because of its simplicity, this type of examination can be easily performed during ambulatory patient care at any level of assistance, thus minimizing factors that may worsen or perpetuate chronic pelvic pain and helping to refer these women to specialized services. However the authors recognize that, scientifically, more objective forms of postural assessment such as biophotogrammetry are necessary. However we believe that the method described here may be useful in assessing the effects of physiotherapy and/or advice to alleviate pain in women with chronic pelvic pain who have musculoskeletal changes.
The authors findings also support the importance of multidisciplinary care, involving physicians, physical therapists and psychologists, for women with chronic pelvic pain. In this series, musculoskeletal changes were associated with chronic pelvic pain in at least in 34% of the women in the chronic pelvic pain group, indicating that a more detailed assessment of women with chronic pelvic pain is necessary for better diagnosis and to provide more effective treatment for these women, including control of situations that may reduce the pain threshold.
Logistic regression showed that the independent factors associated with chronic pelvic pain were postural changes in the cervical spine and scapulae. Musculoskeletal changes were associated with chronic pelvic pain in 34% of women. These findings suggest that a more detailed assessment of women with chronic pelvic pain is necessary for better diagnosis and for more effective treatment
From this study the authors conclude that postural changes are seen more frequently in women with chronic pelvic pain. However, it is not possible to confirm if these changes are causes or consequences of chronic pelvic pain. Thus, more detailed assessments are necessary to obtain better differential diagnosis and, consequently, more effective treatment for these women.
