This text is edited by a physiotherapist and an osteopath from the United Kingdom and pulls together writing from many well-known medical practitioners (Diane Lee, Stephanie Prendergast, Rodney Anderson, Howard Glazer, Jan Dommerholt, and more). The majority of authors are physical therapists or doctors of osteopathic medicine. The text is divided into 20 well-referenced sections. The appendix has full versions of outcomes measures that are very helpful in clinical practice. A DVD with video demonstrations of 1 to 17 techniques per chapter is included with the text. Most demonstrations are very short and do a good job showing the technique, although the quality of the videos varies.
The text begins with a discussion of pelvic pain terminology, etiology, and possible treatment approaches. Chapter 2 has 2 sections of anatomy. Section 1 is a reprint adaptation of Andry Vleeming's chapter of movement, stability, and lumbopelvic pain with anatomy of the trunk and pelvis. Section 2 includes the anatomy of the pelvic floor that is mostly related to urinary incontinence but also includes some content about the nervous system.
The section about chronic pain mechanisms addresses etiology in detail, including central and peripheral conditions. This chapter includes a statement that seems to be true in my practice: "Ongoing and repeated investigations for the 'cause' are associated with worse prognosis," referring to patients who search for the reason for the pain. There is in-depth description of physiology of visceral pain in several sections. The biopsychosocial model is discussed in several sections, including in Chapter 4, which describes the many psychophysiological aspects of chronic pain.
Chapters 6, 7, and 14 address the musculoskeletal component of pelvic pain. Chapter 6 describes the examination of joints and muscles of the pelvis, using the movement system dysfunction first described by Shirley Sahrmann. The video library includes 15 short videos showing how to perform tests. This chapter does note that the accuracy of these tests is questionable in patients with centralized pain. Chapter 7 is a modification of clinical reasoning from Diane Lee's book The Pelvic Girdle. Although the "integrated systems models" include emotional consideration, the focus is tissue-based dysfunction. The video library includes more than 10 videos on examination and treatment during various stages of pregnancy and postpartum. These are interesting but not applicable to the majority of patients with chronic pelvic pain (CPP), which usually occurs in nonpregnant patients. Chapter 14 describes the osteopathic treatment of joints and muscles of the pelvis and trunk.
The multidisciplinary approach from a UK physician's perspective and a US physical therapist's perspective is covered well, along with practical suggestions. This chapter finishes with a section on diet and chronic pain. A very good discussion of diet and inflammation provides suggestions and research that can be easily incorporated into a physical therapist's practice. There is a very short and incomplete discussion of diet and various diagnoses such as painful bladder syndrome and irritable bowel syndrome.
Breathing and CPP are covered extensively in chapter 9. This chapter is worth the price of the book. It is concise and clear with practice explanations of how to evaluate and treat breathing dysfunction. Rational for treatment is provided, and the video library is excellent.
In chapter 10, the content on biofeedback in chronic pain was written by Howard Glazer and Chris Gilbert. It begins with some good information on the physiology of stress and the measurement with EMG. A long discussion follows regarding the problems with the current research and another long discussion about how good the Glazer protocol is. The videos included in this chapter appear to be videos that would be included in purchase of the Glazer protocol targeting the patient using the home device. A short unreferenced list of "new research" gives the reader a look at the future. Unfortunately, the references that are discussed are older than 10 years. There is a good case study at the end of the chapter. The last video is a complete biofeedback case evaluation (about 1 hour) that is well done.
Connective tissue dysfunction is covered in 2 sections of chapter 11. The first section covers external soft tissue treatments. A good background on physiology is provided as it is related to neurogenic inflammation and trigger points. Four soft tissue massage approaches are described, along with specific instruction for many key muscles of the trunk and hips. The DVD includes demonstration of 5 techniques. Fascia and how to treat it (including induction of diaphragm release and cross hand release) are described for external tissues. The second section of chapter 11 is devoted to pudendal nerve dysfunction and connective tissue dysfunction. The chapter starts with a detailed discussion about connective tissue, myofascial release, and skin rolling. Many references are included in this section, but it is difficult to tell the level of evidence (expert option or controlled trials). Techniques are described and 2 skin rolling and one pudendal nerve mobilization techniques are shown on the DVD.
Chapter 12 addresses evaluation and treatment according to the Wise-Anderson Stanford protocol. Pathophysiology of prostate pain syndrome is described, followed by a very complete description of medical evaluation. Other diagnoses are covered in varying level of completeness including orchialgia, pudendal neuralgia, and bladder pain syndrome. Research on pelvic floor muscle trigger points is interesting and provides the basis for their treatment protocol. Pictures of trigger point locations and common symptoms are included. A table of pain referral by muscle is included, but unfortunately this is based on a small number of symptomatic patients with no controls included. Unfortunately, this chapter is poorly referenced and almost 20% of the few references provided were written by the author of the chapter. To be fair, this topic has little research. However, this appears to be another instance of expert option, and promotion of a particular product, rather than a scientific discussion of the evidence.
Functional anatomy is reviewed in chapter 13 in relation to manual release techniques. This is one of the best reviews of functional anatomy I have read and describes the techniques in great detail. Physiotherapist Maeve Whelan explains "direction-specific manual therapy," taking into account the fiber direction in deciding release technique. Male, female, vaginal, and rectal techniques are included. This chapter also includes a discussion of breathing release of the pelvic floor muscle with diaphragm breathing. The video in this section is a very good pictorial display of diaphragm breathing with abdominal wall and pelvic floor muscle relaxation.
Very specific techniques and precautions are given for dry needling, including the superficial perineal muscles, abdominals, and hip muscles. The videos show techniques for 4 muscle groups. Modalities are discussed in some detail with few specifics and not enough to be able to use the techniques in practice. Many of the studies cited are of poor quality and this is not clear in the text.
Creating a comprehensive text on CPP is difficult due to the heterogenetic nature of CPP. It is well accepted that these patients need a combination of treatments for tissue-based dysfunctions and psychosocial-based treatment for central sensitization. Psychosocial treatment is discussed in many locations, but practical techniques are lacking. The text does a much better job at tissue-based treatment. This text is a collection of individual chapters without an overall coordination or order. Many chapters overlap and include differing views on similar subjects. It is a valuable text for all pelvic PTs, especially those with little orthopedic manual therapy education. The accompanying DVD is an excellent teaching tool.
Beth Shelly, PT, DPT, WCS, BCB PMD
Moline, Illinois