WHEN THE PAIN DOES NOT GO AWAY: NOVEL PHYSIOTHERAPY APPROACH IN THE TREATMENT OF PERSISTENT VULVAR PAIN – A CASE REPORT

W. Solomon¹, E. Bassini¹, M. Starzec-Proserprio², S. Hilton³

¹Tor Vergata University, Rome, Italy, ²Centre of Postgraduate Medical Education, Department of Midwifery, Warsaw, Poland, ³Entropy Physiotherapy and Wellness, Chicago, United States

Background: Vulvodynia, a neglected condition considered a chronic primary pain, has lifetime estimates ranging as high as 10-28%. Although several treatments are available, there is a subset of patients in whom the pain persists, even after surgical vestibulectomy. It is of utmost importance to reflect on how to address this problem in clinical settings. A novel physiotherapy approach including the findings from modern neuroscience seems to be a promising option.

Purpose: The aim of this case report was to assess the complexity of pain mechanism and to present novel physiotherapy approach including modern neuroscience adapted to persistent vulvar pain treatment.

Methods: A 28-year-old patient presented to physiotherapy clinic with refractory vulvodynia and symptoms of low back pain. Previous ineffective treatment involved medication, physiotherapy (local and painful manual therapy techniques) and vestibulectomy. The symptoms persisted and patient continued to have pain and burning sensation in the area of removed vestibule, which was substantially limiting her everyday activities, sexual activity and physical activity. Based on the available evidence, the new physiotherapy approach was proposed. It consisted of non-nociceptive manual therapy and techniques targeting central pain mechanisms. Treatment plan included patient-centered, values-based goals, pain neuroscience education, internal manual therapy (including dermo-neuro-modulation) and therapeutic exercise. Outcome measures were evaluated before and after treatment. Pain was assessed with Numerical Pain Rating Scale (NRPS) during Q-tip test (vestibular allodynia) and pelvic floor palpation. Additional outcomes included Oswestry Low Back Pain Disability Questionnaire (ODI).

Results: After completing 10 sessions of the new physiotherapy treatment Q- tip test and NPRS reduced from 8 to 2 points for both vestibular allodynia and pelvic floor pain. ODI decreased from 9 to 3 points. These changes were significantly more substantial than the minimal clinically important change estimated for the used measures. The patient returned to the activities that were previously impacted by her pain (e.g., wearing skinny pants and prolonged sitting). Additionally, she resumed sexual and physical activity (running).

Conclusions: Treatment including drug therapy, local physiotherapy techniques and surgery may not be sufficient to reduce pain in the long term. Patient-centred approach along with physiotherapy targeting central pain mechanisms should be considered for persistent vulvar pain. There are still not enough studies on effective treatments for persistent vulvar pain. Future research[MS1] should focus on effective treatments to reduce the number of invasive procedures for persistent pain. Following the example of other musculoskeletal disorders, creating a framework for treating persistent vulvar pain is warranted.

Implications: The presented, novel physiotherapy approach including pain neuroscience education, non-nociceptive manual therapy techniques and therapeutic exercises is consistent with current recommendations in persistent pain management. It seems to be effective in reduction of pain and pain-related disability also in persistent vulvar pain. Persistent pain management should focus more on global treatments considering also other patient’s conditions that could be drivers of persistent pain.

Keywords:
Persistent vulvar pain
Vulvodynia
Chronic pelvic pain

Topics:
Pelvic, sexual and reproductive health
Pain & pain management
Musculoskeletal

Did this work require ethics approval? No

Reason: Ethics committee approval not needed, the patient was treated using the standard evaluation and treatments. She signed an informed consent to use the her anonymous clinical data, moreover it's describes innovative ways in which established methods have been adapted to meet the changing needs of practice.