A directional preference approach for chronic pelvic pain, bladder dysfunction and concurrent musculoskeletal symptoms: a case series

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Abstract
Background: Chronic pelvic pain (CPP) with concurrent musculoskeletal and bladder symptoms is a complex and challenging problem. However, clinically the co-existence of these symptoms is not routinely questioned, and their musculoskeletal source is not investigated thoroughly. The purpose of this case series is to present the use of Mechanical Diagnosis and Therapy (MDT) principles in seven patients with concurrent chronic pelvic pain, bladder dysfunction and musculoskeletal symptoms. Case Descriptions: Seven patients with coexisting pelvic health and musculoskeletal signs and symptoms were retrospectively reviewed. Most common symptoms were urinary frequency, incontinence, pelvic pain, nocturia, dyspareunia, bladder dyssynergia, and lumbar, pelvic or hip pain. All patients failed to recognize the possible interconnectedness of the two sets of symptoms. Each exhibited a directional preference (DP) and subsequent MDT provisional classification of derangement was established; the use of DP forces abolished or dramatically improved both symptoms and mobility impairments. In all cases DP was for sustained sagittal forces initially, but ultimately lateral forces and mobilization were indicated. Outcomes: Changes in Pelvic Floor Impact Questionnaire, Care Connections Pelvic Floor and Lumbar spine were all clinically significant and exceeded minimally Clinical Important Differences several times. Average of 5.8 sessions per patient was noted. Follow-up at an average of 3.3 years revealed ongoing satisfaction and confidence in independent self-management. Discussion: These case studies highlight the importance of ensuring expansion of intake questions for possible co-existence of symptoms in both pelvic and musculoskeletal patients, possibly suggesting a mechanical intervention is indicated. Provisional subclassification into ‘Mechanical Pelvic Syndrome’ is proposed. Level of Evidence: 4.
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