6.1.1 Patient Presentation

A patient presents with complaints of introital pain. She is unable to partake in intimate activities that involve vaginal penetration. She states that she is experiencing a progressive loss in tolerance to food due to constipation, and that the stress urinary incontinence that she’s been experiencing since the birth of her first child is worsening.

Further questioning reveals that she’s had three spontaneous vaginal deliveries (SVDs) —“just pushed them out”—and returned to work as quickly as possible as president of a Fortune 500 company. She had prepared by having a nanny on call. Prior to marriage she had been a nationally ranked figure skater from 8 years old through college, and confirmed the use of oral birth control from the age of 14 to the present, other than to conceive and give birth to her three children.

Treatments to date include Advil, two tablets TID, and self-directed stretching of her “tight pelvic musculature.”

6.1.2 Evaluation

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  She exhibits extraordinary forward head posture in sitting and standing.

  
  
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  Her angle of declination is 60 degrees.

  
  
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  She demonstrates six finger protraction at the scapulothoracic junction.

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  ALROM is not provocative for reproduction of patient’s symptoms, while there is an apparent decrease of right osteokinematic side-flexion along TL junction.

  
  
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  Mobility and provocation tests of the sacroiliac joint SIJ are negative.

  
  
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  She demonstrates a positive prone knee flexion (PKF) on the right, and straight leg raising (SLR) is unremarkable bilaterally.

  
  
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  Segmental screening for strength and sensation along the L2-S2 nerve roots is unremarkable.

  
  
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  Increased resting tone throughout the pectoralis minor, sternocleidomastoid, suboccipital group and iliopsoas musculature noted.

  
  
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  She demonstrates an extraordinary apical respiration pattern.

  
  
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  Pelvic examination:

  
  
  
  
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    Upon visual inspection, vaginal inversion is noted where the increased muscle tone of the pelvic floor resulted in the clitoris and anus facing each other

    
    
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    Coughing, sneezing, and straining (CSS) were negative

    
    
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    Volitional contraction of the pelvic floor musculature (PFM) demonstrates minor lift and slow/modest release; adductor and gluteal accessory contractions noted

    
    
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    Upon initiating contact to the ischial tuberosity for the pelvic mapping/palpation, the patient violently withdraws but demands that the evaluation “continue”

    
    
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    Bulbospongiosus reflex was negative bilaterally

    
    
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    Vaginal sweep was positive for scarring along 11:00 at and along the vaginal-uterine interface

    
    
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    Sacral tinel testing was negative

    
    
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    Increased tone noted throughout the PFM right > left

6.1.3 Treatment Strategy

In order to best address this patient’s pain, where would you initiate your treatment? Complete the listing below, and devise a subsequent treatment strategy for each of the following:

1. 
   

   Psychology of pain:

   
   
2. 
   

   Neurological considerations:

   
   
3. 
   

   Joint restrictions:

   
   
4. 
   

   Scars:

   
   
5. 
   

   Muscle imbalance and generalized weaknesses:

   
   
6. 
   

   Muscle spasms and fascial restrictions:

In order to address the patient’s psychology of pain, she is to be instructed towards the attaining of proper, erect posture. She is to be given means to attain an optimal sitting and standing alignment. McKenzie lumbar support and the like can be introduced. Using a mirror, this patient is to be shown the difference between apical respiration and diaphragmatic respiration patterns. With the use of a mirror, or the supine, book strategy, the patient is to initiate changes in her respiration patterning.

Neurologically, the positive PKF is to be addressed with segmental mobilizations at the T12–L3 junctions. Techniques as outlined in this text, the side-lying rotational mobilizations, or other localized joint specific techniques can be used. After the performance of a joint specific mobilization, the resting tone of the PFM is to be visualized and assessed to determine whether or not there was a change. Many clinicians and patients alike are wonderfully surprised when such a remote treatment has a positive impact on the patient’s pain, and resting tone.

Joint restrictions of the thoracic spine are to be segmentally evaluated and treated where they are found. Due to the hyperkyphotic nature described and the predominance of a strong apical respiration pattern, it is very likely that local restrictions will be found.

The scars of the birth canal noted with the vaginal sweep are to be addressed with a gentle transverse friction massage (TFM) (Fig. 6.1) . The scar is to be located and gently addressed. If the local pain is significant, consider assessing the thoracolumbar junctions and treating there locally prior to continuing the TFM as the pain may be initiating and enhanced centrally (remember the proximal three-quarters of the internal genital symptoms are conveyed via the hypogastric, pelvic, and vagus nerves to the T5–L2 spinal segments). TFM is to continue at patient’s tolerance.

Addressing the patient’s muscular imbalance and generalized weakness will involve strengthening of the mid/lower trapezius, the erector spinae, and the abdominal musculature. Examples of these exercises are provided below.

If fascial restrictions persist, the use of ice, in conjunction with the elimination of local joint restrictions, will improve the local mobility. Over the course of the first week of treatment, the clinician and patient alike should notice a marked improvement of local fascial mobility, and improved comfort if the patient is actively participating in the postural changes described, and the clinician is providing appropriate joint specific treatments.

6.1.4 Exercises (Fig. 5.13 , Fig. 5.14 , Fig. 5.15 , Fig. 5.16)

The clinician is to progress as is tolerated by each patient. No exercises are to hurt other than typical muscle fatigue and “burn”. Pain is to be avoided as pain begets pain. As clinicians we do not want to be a contributor to the enhancement of a patient’s pain. Verbal encouragement is often quite necessary and appropriate as those that are suffering are often in poor physical and emotional health.

6.2.1 Patient Presentation

Patient presents with primary complaints of vulvodynia and dyspareunia. She is a 51-year-old woman with a history of two SVDs, 18 and 20 years ago. She denies trauma or a specific event that would have provoked her symptoms. She states that she had gained approximately ten pounds over the past year, and that she finally decided to “take it off.” She hired a personal trainer that has her progressing along with her fitness activities. She states that she does not enjoy the workouts, but understands the need to exercise. She reports that the personal training now entails jogging for 1.5 miles and performing a series of box-jumps, burpies, and a variety of high-intensity plyometric exercises.

6.2.2 Evaluation

Her symptoms often are noted upon standing from the sitting position, and after standing for more than thirty minutes, along the lumbosacral region with radiations to the groin. She reports a progressive inability to wear high heels as her pain becomes intolerable after fifteen minutes. She further states that she had enjoyed lying on her back on the wooden floor of her apartment to relax, but no longer can tolerate this position due to a progressive building of ache, pain, and distress along the lumbosacral region. She states that her right more so then her left buttock is hurting; spasms are present.

When she attempts to be intimately active, she experiences pain upon penetration, but that external contact and clitoral stimulation are normal. She has greater tolerance to penetration while in the rear-entry position, while her preferred position (missionary position) is becoming intolerable.

She finds herself thinking frequently about her pain, and often digitally “checks” her pain during bathroom breaks to see if she is tolerating vaginal penetration on any given day. To her dismay, she is tolerating digital contact and penetration less and less each day.

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  Patient stands with an angle of declination of 65 degrees bilaterally.

  
  
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  Patient demonstrates five finger protraction bilaterally at the scapulothoracic joint (STJ).

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  ALROM is unremarkable other then an absence of lumbar lordosis reversal in full flexion.

  
  
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  Myotomal/dermatomal screening of lumbosacral nerves is unremarkable.

  
  
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  Gillet and standing flexion tests were positive on the right.

  
  
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  Neural tension testing of the sciatic nerve is unremarkable.

  
  
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  Prone knee flexion test is provocative for pain at the right > left SIJ; positive Nachlas test.

  
  
  
  
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    When the hip is extended, and the prone knee flexion maneuver is performed, the pain is more pronounced at the ipsilateral SIJ; Yeoman’s test.

  
  
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  SIJ compression is mildly provocative on the right, negative on the left for local symptoms along the SIJ, while SIJ decompression is alleviating of vulvodynia symptoms.

  
  
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  ASLR is unremarkable.

  
  
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  FABER, FAIR, McCarthy and tests for the posterior labrum are unremarkable.

  
  
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  When the hip is flexed, adducted toward the contralateral coxofemoral hip and then an axial pressure is exerted through the femur, the patient complains of her inguinal/vulvodynia pain right > left.

  
  
  
  
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    Stressing iliolumbar ligment

  
  
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  Positive “Dead Butt Syndrome” findings right > left.

Clinical question: would you perform an internal pelvic examination at this time? If so, what clinical indications do you have to justify the progression of the evaluation? If not, why would you choose not to perform an internal evaluation as she has a history of two SVDs, and penetration dyspareunia?

6.2.3 Treatment Strategy

In order to best address this patient’s pain, where would you initiate your treatment? Complete the listing below, and devise a subsequent treatment strategy for each of the following:

1. 
   

   Psychology of pain:

   
   
2. 
   

   Neurological considerations:

   
   
3. 
   

   Joint restrictions:

   
   
4. 
   

   Scars:

   
   
5. 
   

   Muscle imbalance and generalized weaknesses:

   
   
6. 
   

   Muscle spasms and fascial restrictions:

Psychology of pain: the patient is to be advised and encouraged to avoid the persistent self-evaluation and perseveration over her vaginal penetration pain. Constant attention thereto will enhance her local pain due to the activation of the RVM/PAG, and with repeated noxious stimulation to the region she unknowingly will enhance her pain via central and peripheral sensitization.

Neurological considerations: The prone knee flexion was positive, but the patient’s reported symptoms were along the SIJ ipsilaterally, and the symptoms increased with hip extension. This process indicates more involvement of the SIJ then the femoral nerve. This, coupled with the positive Gillet and standing flexion tests, a reduction of symptoms during SIJ decompression, and stress testing of the iliolumbar ligament, indicate a great likelihood of SIJ involvement. The Dead-Butt syndrome findings further indicate local involvement of the SIJ. The coxofemoral joint and related structures appear to be unremarkable. Treatment is to be initiated at the right SIJ. Local transverse friction massage to the iliolumbar ligament, followed by a local SIJ traction and mobilization to the SIJ as outlined by Grieves offered the patient great relief of her vulvodynia pain (Fig. 6.2) .

Scars: There were no scars noted, but crepitus was noted along iliolumbar ligament.