Musculoskeletal and Neurological Pelvic Pain - A Physiatrist’s Handbook-Session Presentation

Session Presentation

Video Transcription

Good evening, everybody. Before we begin, just the housekeeping information, which you've seen a lot during this assembly.  So we will be posting a poll question just to get a feedback on our audiences. So if you could please take time to complete these poll questions, we'll really appreciate it.  Please type in your questions on the chat box, and we'll try to get through these chat questions during the talk.  And if there are any unanswered questions, please feel free to reach out to us by email.  So, the topic for today is going to be musculoskeletal and neurological pelvic pain from the physiatrist's perspective.  So, I'd like to begin by thanking AAPMNR for providing us this opportunity to talk about the musculoskeletal and neurological pelvic pain.  At this time, I would also like to thank Dr. Colleen Fitzgerald, who basically laid the foundation for a physiatrist's involvement in treating pelvic pain.  She has inspired and mentored a lot of physiatrists in the country, including me, and has contributed a lot to the advancement of pelvic pain literature.  So, we all know that international physiatrists practice in a wide variety of settings, mostly  multi-specialty groups such as orthopedics or neurosurgical groups, as well as independent solo private practices, where there may not be enough resources for a multidisciplinary  pelvic pain management. So, the goal for this talk is to provide an overview of a clinical approach to a patient  presenting with pelvic pain and explore all the non-interventional and the interventional strategies that can be incorporated in a wide variety of physiatrist settings to best help  these patients. So, to this goal, we have prepared four talks, and at this time, it is my pleasure to introduce our co-speakers for this talk. We have four excellent speakers.  The first talk would be given by Dr. Stacey Benes. She will be talking about the clinical assessment of a patient with chronic pelvic pain from a physiatrist's perspective.  She is a board-certified physical medicine and rehabilitation specialist and sports medicine specialist practicing at Loyola University Medical Center in Chicago.  She is an assistant professor working at the Department of Orthopedics, as well as PM&R,  and treats a wide variety of sports and musculoskeletal pelvic pain conditions, and she will be presenting on this topic on clinical approach.  Following her talk would be my talker, Malathi Srinivasan, a board-certified physical medicine and rehabilitation specialist practicing as an interventional physiatrist at Rockman  Orthopedics in Philadelphia, and an assistant professor of physical medicine and rehabilitation at Thomas Jefferson University.  I'm also board-certified in obstetrics and gynecology from England, and I have a special interest in women's health.  I will be talking about the basic injection interventions for musculoskeletal and neurological pelvic pain.  Following my talk would be Dr. Amit Nathpal, who is a division chief of pain medicine at the University of Texas Health Science Center at San Antonio School of Medicine.  He is a clinical associate professor and associate program director for the pain medicine fellowship in anesthesiology.  He is board-certified in physical medicine and rehabilitation, as well as pain medicine. He will be talking about the evidences for advanced interventional approaches for patients  with pelvic pain. And lastly, my colleague, Dr. Saloni Sharma, is a board-certified PMNR and pain medicine specialist.  She is board-certified in physical medicine and rehabilitation and pain medicine and practices at Rockman Orthopedics in Philadelphia, and a clinical assistant professor of PMNR at  Thomas Jefferson University. She serves as a co-chair on the Academy's OPI Task Force, as well as the Pain and Spine Rehabilitation with the Academy.  She is a big advocate for non-OPI alternatives for pain management, and is a founder of the Orthopedic Integrative Medical Center Program at Rockman Orthopedics.  It's a program that focuses on non-OPI management of pain with integrative options. She will be talking about the biopsychosocial model of care and the treatment of chronic  pelvic pain. So with that, I will stop sharing and pass it on to Dr. Stacy Dennis.  Thank you, Dr. Srinivasan. It's a pleasure to be here today. We're going to go through the physiatrist evaluation of chronic pelvic pain. I have no disclosures. We'll review the  physiatric approach to the history and physical exam in chronic pelvic pain. Oh, sorry.  As well as introduce non-interventional treatments for chronic pelvic pain.  Chronic pelvic pain is defined as pain perceived to be originating from the pelvis, typically  lasting more than six months and is often associated with negative cognitive, behavioral,  sexual, and emotional consequences and symptoms suggestive of lower urinary tract, sexual, bowel,  myofascial, or gynecologic dysfunction. The pain may be non-cyclic or cyclic or related to menstruation such as dysmenorrhea or intercourse dyspareunia. Up to 25% of women  and 2 to 16% of men suffer from chronic pelvic pain and this prevalence is consistent with other  chronic pain syndromes. There are many chronic overlapping conditions that coincide with chronic  pelvic pain, including visceral conditions, such as endometriosis, irritable bowel syndrome,  interstitial cystitis, or bladder pain syndrome, musculoskeletal conditions, such as pelvic floor  myofascial pain, vulvodynia, neuropathic pain, such as pudendal neuralgia or other cutaneous  neuropathies, fibromyalgia, hypermobility spectrum disorders, and neuro and psychiatric conditions,  such as depression, anxiety, history of trauma or abuse, migraine headaches. So you have to keep a  pretty wide differential diagnosis for these patients and keep all of these conditions in mind as you're treating. A recent Loyola chronic pelvic pain study found that the  most common diagnoses in women's chronic pelvic pain were pelvic floor myofascial pain and musculoskeletal disorders, such as the lumbar spine, pelvic girdle, and hip,  and these were occurring in 50 to 90 percent of patients with chronic pelvic pain and presented a  greater prevalence than visceral diagnoses that are more commonly thought of with chronic pelvic pain.  When treating these patients, it's important to practice trauma-informed care. So in the history,  you always want to screen for trauma, abuse, and distress, and ideally you might consider taking  the history with the patient dress to keep them more comfortable. When you do your physical exam,  again, following a trauma-informed care approach, you should explain the steps of and the reasoning  for the pelvic examination, obtain consent before starting and throughout the exam, consider having  a chaperone or assistant present. This would be optional if it's provider-patient same sex, but  really would be mandatory if it's different sex provider patient or if the patient is under the  age of 18. Patients have the autonomy to stop the exam at any point and also have the autonomy to  ask questions and choose what is or isn't done during the exam, and it can be helpful to offer the patients a mirror to visualize their anatomy if they're interested in this option.  So we'll next talk about the physiatric approach to the chronic pelvic pain history.  So as we know, as pubinar physicians, we do a very detailed history in general, and this would include taking a detailed history of the presenting pain complaint,  typically looking at onset, provoking and palliating factors, the quality, region, and radiation of the pain, the severity, the timing and temporal relationship, any treatments,  and I particularly like to ask what has been the most helpful thing you have ever tried for your  pain, as well as any associated symptoms and associated history, which can get quite complex,  as you'll see next. So we'll take a very detailed musculoskeletal history and remembering that  MSK pain and dysfunction are found in 50 to 90 percent of patients with chronic pelvic pain,  from that Loyola study that found back pain, hip pain, and pelvic girdle pain were the most common presenting complaints, as well as any history of prior MSK imaging or procedures,  any analgesic or anti-inflammatory medications, and if they follow with a sports medicine or a pain physician, I take the name and add them to my multidisciplinary team.  It's always important to watch out for MSK red flags. These are chronic pelvic pain patients, but you still don't want to miss these. So any history of trauma, neurological signs,  malignancy signs, prolonged corticosteroid use, constant or severe pain, recent infections,  fevers, and chills, IV drug abuse, and you know, of course, you never want to miss cardiovascular  symptoms, which are referred, you know, somatic pain presenting from visceral pain.  I always take an associated neurologic history, including any history of migraine headaches, upper motor neuron diagnoses, such as a spinal cord injury or multiple sclerosis,  lower motor neuron diagnoses, such as cauda equina or peripheral neuropathies, including  large or small fiber diagnoses. If they've had a prior EMG nerve conduction study, I like to know  the results of that, as well as if they've had any prior labs or nerve biopsy as part of a neuropathy  workup, neuropathic medications. And again, if they follow with a neurologist, I add them to my  team. Rheumatologic history, also important. I ask about any history of fibromyalgia, chronic fatigue  syndrome, any inflammatory or autoimmune conditions, including joint hypermobility, which is known to overlap with chronic pelvic pain, among others. Whether they're on any  rheumatologic medications, I'll take a rheumatologic review of systems where appropriate. And again, if they follow with a rheumatologist, I add them to my team.  GU, GI, and gynecologic history is also very important in these patients with those overlapping  visceral diagnoses. So I want to know any prior GI, GU, or gynecologic conditions, medications,  procedures, surgeries. I do take a detailed GI, GU, and gynecologic review of systems.  I kind of make, I try to make sure their preventive screenings are up to date, including colonoscopies and pap smears. And again, if they have these specialists that they're already  following with, I take their names and add them to my team. Psychiatric history, again, very  important. I want to know if they have depression, anxiety, PTSD, if they're sleeping okay, if they're  on any psychiatric medications, or if they've had prior psychiatric hospitalizations. And again,  following the trauma-informed care approach, I want to know if they have a history of trauma or  abuse. And again, adding their psychologist, social worker, or psychiatrist to my team.  For social history, I screen for substance use and abuse, their employment status, their exercise  status, and I try to always counsel my patients on the CDC recommendations for cardiovascular and  resistance exercise. So I think that's a very important non-pharmacologic treatment for these  patients. Leisure time activities and hobbies, their marital status and home support, and their  sexual history. So once you've taken that very detailed history, it's time to go on to your  physiatrist neurologic and musculoskeletal exam.  Always, you start with observation, looking at body mass index, appearance, posture, alignment,  their gait. I always check a neurologic exam following an ASIA approach for the L2 to S2  myotomes for strength, dermatomes for sensation, and the L4, L5, and S1 areas for reflexes, as well  as checking for Babinski or Hoffman's when appropriate. I do a detailed external physical  exam, including the lumbar, spine, pelvic, girdle, and hips, including palpation, range of motion,  and provocative testing. I try to do that external exam first, keeping the patient dressed where  possible for comfort, especially if I do find that they have a history of trauma or abuse during the  history, and then I, with consent, perform the pelvic floor exam second. For special tests, I  typically include the seated slump maneuver to look for radicular pain, the straight leg raise,  again, also looking for radicular pain. For the pelvic girdle, I typically will perform a favor,  looking for SI joint pain, a P4, again, also looking for SI joint pain, and a pelvic distraction  maneuver, again, also looking for SI joint pain following the Laslett maneuvers, and there are  more, but those are typically the three that I go to first. I also do a pubic symphysis palpation test,  a modified Trendelenburg maneuver, which is looking for pain at the pubic symphysis, not looking for gluteal weakness, although that would be important to note as well,  and I also, in many of my patients, check for diastasis rectus abdominis, which is widening of  the abdominal muscles, and most commonly seen in pregnant and postpartum women, but can persist for  many years in a subsegment of the postpartum population, and it does have implications for  core stability and pelvic floor symptoms, so this is one that's an extra that I'll add on in this  population. For the hips, I perform a favor maneuver, looking for hip pain, a fader maneuver, again, looking for hip pain, particularly you might find this in hip impingement or hip  osteoarthritis, and a resisted active straight leg race maneuver. I might also screen for joint  hypermobility, if I'm concerned for that in the patient that I'm seeing, and I do use Byton's  score for this, where I look for fifth-digit hyperextension, the ability to get the thumb  to the forearm, elbow and knee hyperextension, and the ability to get both palms to the floor  in standing forward lumbar flexion. If they score between four to nine out of nine points, I would consider sending them to rheumatology for workup for connective tissue disorder,  if this hasn't been done already. Once I've done the external exam, I move on to the pelvic floor  exam. So it's important to know your hospital's policies about pelvic exams, as some hospitals do require written consent. I document the discussion, the presence and absence of a  chaperone and the verbal consent in my note, and I have a clear discussion with the patient that  I'm really looking at the nerves, muscles, and bones, and not the pelvic organs, but that we  work with our colleagues who perform a visceral pelvic exam to allow them to look at those  structures. So I start with inspection externally, and I'm looking for a lift or contraction of the  pelvic floor versus a descent or relaxation. I'll have the patient perform a Kegel for voluntary  contraction. I'll have them let the Kegel go to look for voluntary relaxation. I'll have them  cough or exhale for involuntary contraction, and to perform a deep inhalation for involuntary  relaxation. I'll then move on to check sensation, checking dermatomes and cutaneous nerves as  appropriate, and typically starting with light touch, but could add pinprick and pressure,  particularly if you're concerned for reduced sensation. And I'm looking for reduced sensation,  normal sensation, or increased sensation, such as you might see with aledinia or hyperalgesia.  So these are the sensory dermatomes of the pelvic floor.  And also important to know the cutaneous sensory nerves and the ones that you would be most likely  to look for in this patient population would be the iliohypogastric nerve, the genitofemoral nerve,  ilioinguinal nerve, lateral femoral cutaneous nerve, the pudendal nerve, including its inferior rectal perineal and dorsal nerve to penis or clitoris branches, the posterior femoral  cutaneous nerve, and the medial inferior and superior clunial nerves. I also check for  aledinia of the vulva or vulvodynia using a Q-tip test, and you test at multiple areas with a cotton  swab. There's no formal consensus on the points that are tested. One study used up to 23 points,  but I typically, if you think of this as a face of a clock, check at 12, 3, 6, and 9,  and you would ask for a numeric rating scale of pain on a zero to 10 scale at each of those points.  Then you move on to palpation. You're palpating for tenderness, trigger points, which is a hallmark finding in myofascial pain, and these can be active or  latent. You're looking for tone of the muscles, whether that's increased, normal, or decreased.  Typically, you use the index finger of your dominant hand. I always orient the patient  by pressing on their rectus femoris or adductor muscles to show them how much pressure I'm going to be using, and you use about enough pressure to blanch your fingertip.  The superficial pelvic floor muscle palpation exam hasn't been validated, but  this is fairly widely used in clinical practice. I'll press on the perineal body, the transverse perineal muscles in blue, the ischiocavernosus muscles in red,  and the bulbo cavernosus muscles in green, and at the posterior triangle is the levator, ani, and coccygeus muscles, which are deep, but you can try to palpate these externally.  Internally, this has been validated. You palpate the levator ani complex, which is found from nine o'clock to six o'clock and three o'clock to six o'clock,  and the obturator internus, which is found from 12 o'clock to nine o'clock and 12 o'clock to  three o'clock on either side, and to activate this muscle, you can ask the patient to abduct  her ipsilateral thigh against your hand that's on her knee in order to activate the muscle and feel  that more easily. The rectal exam has also not been validated, but is used quite commonly in  practice among pelvic pain specialists and pelvic floor physical therapists, and what you want to do  on the rectal exam is palpate the external anal sphincter for tone, pain, spasm, or defects,  palpate the coccyx at six o'clock, assess for coccyx mobility in both flexion and extension, and you're looking for hypo or hyper mobility, and you can palpate the coccygeal muscles  bilaterally at nine and three o'clock. Then you want to check for strength. There's many research measures that are used for strength assessment of the pelvic floor, but our current  gold standard in clinical practice is a manual exam using a modified Oxford scale. In patients  who are uncomfortable, you could also consider visual observation looking for presence or absence  of a lift in a patient who's not amenable, but the other modalities listed here are more for  research purposes. So the strength exam, again, you use the index finger of your dominant hand.  It's a similar approach. You could check each muscle, though I typically only check at midline  for global muscle function, and I'm looking for absence or presence of a lift, which is essentially  what we think of as antigravity on our strength scale, and you do grade them on a zero to five.  So zero is no contraction. A one would be a flicker or a pulsation. A two, you could feel  tension, but there's no lift. A three is defined by lift. A four, you have good lift and some  contraction and some resistance. And a grade five, you have lift with strong resistance, and it feels like the finger is being squeezed and drawn into the vagina or the rectum.  All right, so we got through our history and our physical exam, and now we're thinking about  non-interventional treatments that we can use for this patient population. This is a notoriously challenging group to study. They're very heterogeneous, as you can imagine, and a  multimodal individualized approach is generally recommended. There are some algorithms for some  of the CPP overlapping diagnoses, such as IC bladder pain syndrome, IBS, and vulvodynia, but we're not going to cover those in detail today. Physical therapy is traditionally first  line for chronic pelvic pain. Physical therapy should be individualized, and two recent systematic  reviews did find beneficial effects with physical therapy, but they were quite heterogeneous. So we  kind of know it works, but we need further high quality research, especially randomized controlled trials. For pharmacologic treatments, there are no randomized controlled trials in  chronic pelvic pain for anesthetic agents, estrogen, or compounded creams, although  there is some evidence to support that overnight lidocaine ointment  or topical estrogen may be helpful in some of these subpopulations.  Again, no randomized controlled trials for analgesic medications or muscle relaxant medications.  You might consider acetaminophen and NSAIDs for acute pain, such as cyclic pelvic pain,  and obviously, you know, you try to avoid opioids unless it's a cancer-related or post-op condition.  Gabapentinoids, there was a recent really high quality randomized controlled trial in 2020 that  found no benefit of gabapentin in chronic pelvic pain compared to placebo at 16 weeks in pain or  function, and a recent systematic review of vaginal valium suppositories, which is quite  frequently used, did not show any clear benefit, and that included three randomized controlled trials.  Antidepressant medications, for tricyclics, SSRIs, and SNRIs, there's no randomized controlled  trials in chronic pelvic pain specifically, but tricyclics are included in the vulvodynia, IBS, and IC bladder pain syndrome treatment algorithms, and SSRIs are included in the IBS  treatment algorithm. So, these are medications that are quite commonly used in the chronic pelvic pain population. So, to summarize, there's no randomized controlled trials for  the history and physical exam should be trauma-informed. The history taking is thorough and systems-based. The exam should include external MSK conditions, such as spine, pelvic,  girdle, and hips, as well as a pelvic floor muscle exam. PT is our first line non-interventional  treatment. Medications are used commonly, but have little evidence, and we definitely need more  research in chronic pelvic pain for the exam and for treatment. My references were included  throughout, and thank you all for your attention, and I'm going to pass it back over to Dr. Srinivasan.  Thank you, Dr. Benes, for that excellent talk about the interaction for clinical approach to a patient presenting with pelvic pain. Let me just minimize this.  All right, so we know that chronic pelvic pain is, so we'll be talking about the injection  interventions for pelvic pain. We know that chronic pelvic pain is complex, it's debilitating,  it's non-malignant, and it's very nonspecific and has a variety of diagnosis, and we know that it  does affect quite a significant proportion of women. About 2 million women are affected at  any given time with pelvic pain. So interestingly, as Dr. Benes explained as well in her talk,  majority of the patients, about 85 to 95 percent of these patients, have a strong myofascial  component that causes this pain, which is where as physiatrists we have a huge role to play to  help this patient population. So when and how to select the injection options that are likely to  help these patients, traditionally the thought process has always been when all the reversible  causes for nociception has been treated and patients have failed non-invasive treatment strategies, including pelvic floor physical therapy, that's when patients are referred for  injection options. But based on the available evidence, we like to propose that these patients  should be considered for injection options in conjunction with other non-invasive treatment strategies, including pelvic floor physical therapy. So the goal would be to identify the  pain generator as early as possible. So the theory being the sooner you identify the pain  generator and treat the acute inflammatory process, it's less likely to lead to a chronic pain condition. So we will explore those evidences for some of the injections in this talk.  So how do we position ourselves better to offer these options for our patients?  We need to have a good understanding of the pelvic musculature and its innovation.  We also need to have a narrow differential diagnosis. Based on our history and physical examination, we have to have a clear problem focused approach to help these patients. And  we also need to have all the available evidences, again, for these injection interventions  to guide these patients appropriately through them. So without going into too much details  into the anatomy of the pelvic region, we know it's complex. We know that the pelvic region has  a significant overlap of the dermatoma distribution, very similar to the lower extremities.  The dermatomas from L1 to SY innervate the pelvic region. So if we need to trace back these dermatoma distribution of pain to the corresponding nerve root, it can be very  challenging because of this overlapping nature. So a good working knowledge of the sclerotomal  distribution of pain for the peripheral nerves could be very helpful. So even though the pelvic  neuroanatomy is very complex, the nerves that are most likely to be causing pain in the pelvic  region essentially are the three nerves, which are the iliohypogastric, ilioinguinal nerves,  the genital and the femoral branch of the genitofemoral nerve, and the pulmonary nerve. So  if we know the sclerotomal distribution of this pain, then we could help plan injection interventions  based on the presentation. So it's also important when we talk about the pelvic region, we need to  understand that the three systems that play a role in pelvic pain, the autonomic nervous system,  the visceral nervous system, and the somatic nervous system. The somatic nervous system is  the nervous system that innervates the musculature of the pelvic region, and the visceral nervous  system innervates the organs in the pelvic region. And they all share a lot of pathways in the pelvic  region and relay a lot of information to the plexus before they travel to the spinal cord.  So at the level of the spinal cord at each nerve root segment, we know that there is the ventral  ramus and the dorsal ramus. The ventral ramus is where there is a lot of information going back  and forth between the somatic nervous system and the visceral nervous system. But in this area,  we also have to understand this, the autonomic nervous system receives a branch from the ventral  ramus and relays the information back to the ventral ramus. So in this area, all these three  nervous systems have a lot of overlap and cross-sensitization that happens at this level, which is why there is a lot of overlapping pain syndromes in pelvic pain patients.  And we know that this information from the root level also travels all the way along the spinal  cord through the sympathetic and the parasympathetic ganglion and relays this information to the brain.  So when we plan for injection options for pelvic pain, even though we always want to think outside  the box, the pelvic pain population, it can get really confusing with the overlapping picture of  the varying presentations. So sometimes it's helpful to keep it simple and put them in the  boxes to help us more. So based on our history and physical examination, if we have a strong  suspicion for a myofascial component of pain, then the injections that are most likely to be  helpful for these patients are the levator RNA trigger point injections and the piriformis and  outreter internus trigger point injections. If we suspect a neurological component for pain,  then these patients can be helped with some nerve blocks, depending on the location of their pain.  If a patient presents to you with an isolated pain along the ilioinguinal, iliohypotastric,  or the pedundal nerve distribution, they are most likely to be helped with the peripheral nerve  blocks. If a patient has pelvic pain, but predominantly bilateral symptoms, then they are, that is so confined to the pelvis, they may be helped with advanced interventions like  plexus blocks and ganglion and power blocks. But if a patient has presented with more centralizing  symptoms with central sensitization, then they would be candidates to be considered for advanced  interventions like neuromodulation. So when we decide on injection options for patients,  majority of these pelvic pain injections are done with image guidance. There are a few pelvic  injections that can be done without injections, which are without image guidance, which are the  peripheral trigger point injections for the levator RNA muscles and some peripheral nerve blocks.  So we'll start with evidences for the levator RNA trigger point injections.  Levator RNA trigger point injections are very similar to trigger point injections in any other muscle in your body. It can be done as an office procedure without any image guidance,  patients are placed in a dorsal lithotomy position and identifying the trigger point by palpation through the vagina to identify the levator RNA muscles. And once the muscles are  identified to be the source for trigger point, the needle is advanced using finger guidance.  And after aspiration and withdrawal, a mix of local anesthetic with or without steroid can be injected  to these muscles. So earlier studies on trigger point injections for pelvic floor comes from the urological literature, predominantly patients having pelvic  floor dysfunction after interstitial cystitis. These injections were found to be helpful  to provide a significant percentage of pain relief after first injections. However, these early  studies were not placebo controlled. They did not account for pelvic floor physical therapy.  So there were some subsequent studies that were done comparing pelvic floor physical therapy with  trigger point injections for the levator RNA muscles. These studies showed that both groups  had an equal percentage of improvement with both the options. However, when they looked at the time  for improvement, the time to effect favored the levator trigger point injections more than physical therapy. Subsequently, there were other retrospective studies published  on a large number of patients who received steroids for trigger point injections for levator RNA muscles and showed significant percent improvement in pain scores.  And these studies also recommended that these injections can be used as part of a multidisciplinary approach for managing chronic pelvic pain.  So these responses to the steroid injections also triggered some interest towards using botulinum toxin for pelvic floor. And one of the early studies done in 2004 that studied 12  patients showed a 37% reduction in the pelvic floor muscle tone when Botox was used for these injections. And the reduction in the tone was also maintained at 25% at three months.  Subsequently, there was a large randomized trial that was published in Australia in 2006, where they compared 30 patients who received botulinum toxin compared with placebo for 30  patients and showed a significant reduction in non-menstrual pelvic pain, pain during intercourse.  There was also significant reduction in pain during bowel movement and the resting pressure and the maximum contraction pressure in these studies where Botox was used.  However, there was another study that was published in 2019 in Boston, which was a prospective double-blind study on 21 patients. Granted, the numbers were not as much as the  previous randomized study in 2006. They compared patients who received steroids versus Botox,  but did not find a significant difference with using Botox. Both groups showed significant improvement in pain. However, Botox was not the one that made the difference.  So the difference in the outcome could be mainly because of the difference in the methodology  of the studies. The Australian study used the general manometry to assess the general  pelvic floor tone and did not account for any prior physical therapy. But Boston study did not  have any objective measure for pelvic floor tone, but did include patients who had physical therapy  prior as well as for eight weeks after the injection. So there is a significant difference in the methodology. So more recently, there was a meta-analysis that is published on the  effectiveness of Botox on myofascial pain that included nine studies that are published on  Botox. It actually included two randomized trials and a few prospective studies. All these studies  had some variation in the methodology and difference in the dosage of the Botox that  were used in between 20 and 300 units. However, the pooled data did show that there is a favorable  response to improving the pain outcomes with using Botox for levator adenine muscle.  So the results of this meta-analysis shows that there is a statistically significant difference  at six weeks, which is maintained at 12 weeks. And there's also some significant improvement in  quality of life outcomes like dyspironia and pain during bowel movement. So we are still in need of  large randomized trials, but there is some evidence to support Botox to use for these muscles.  We'll then move on to the peripheral trigger point injections. Peripheral trigger point injections have been studied in patients presenting with deep back pain who are  unresponsive to traditional treatments. When combined with a physical therapy protocol,  trigger point injections for their peripheral muscles were shown to have a good percentage  of patients improved when combined with their physical therapy protocol in earlier studies.  Subsequent studies have looked into using image guidance for peripherals for more appropriate localization of the injection and did find that ultrasound-guided injections  found cost some significant reduction in the pain scores. And other studies also showed that the  effect was maintained for a few weeks with using image guidance for peripheral injections.  Other studies also looked into what kind of image guidance would be more helpful.  They did not find a significant difference whether ultrasound or fluoroscopy was used for  peripheral trigger point injections. One study also looked at what was the injector used for peripherals, whether the steroid was making the difference versus the lidocaine,  but this particular study did not find a significant difference whether lidocaine was used by itself versus combined with the steroid use, which subsequently triggered  some interest in the role of hydro dissection, where there could be some dilution effect of the  inflammatory mediators in the trigger point in peripherals. This particular study showed there was a significant reduction in the pain when hydro dissection was combined with  steroid injections for peripherals. And for the peripheral muscle as well, the use of botulinum toxin has been studied. There is one class two randomized trial that  has been published that showed significant improvement in pain scores. There was also several case reports that are published on peripheral injections that are found to be  helpful. However, right now this is only recommended for peripherals for severe refractory  pain due to the deeper location of the muscle and the closer proximity to the vascular bundle.  And image guidance is definitely recommended for periformis injections.  This is a picture of a fluoroscopy guided periformis injection, which is what we do in most international physiatrists are comfortable with using fluoroscopy, and there are  clearly defined landmarks identifying the inferior sacroiliac joint, one centimeter inferior,  lateral, and deeper to the inferior sacroiliac joint is where you would find the periformis muscle. Once the needle is advanced and the change of resistance is felt to the muscle,  contrast is placed to verify that the flow is across along the periformis muscle, and it can  be confirmed on lateral view as well to make sure that the injection is done at the right area.  So next we'll move on to the nerve injections, some of the basic peripheral nerve injections  that we can perform for these patients based on the diagnosis. The commonly performed peripheral  nerve blocks are the ilioinguinal, iliohypogastric, and genitrofemoral nerves. They get commonly injured in lower abdominal incisions after hernia repair, appendectomy, laparoscopic  incisions, and C-sections, and patients who typically present with pain in the groin refer  to the scrotum or the testis or the inner thigh or the labia, and these nerves can also be trapped  after laparoscopic surgery for endometriosis and hernia repair, and response to diagnostic  injections can be very helpful to be identifying the pain generator. So traditionally these blocks  are performed predominantly using a landmark-based approach. There's well-described  landmark-based approaches for these injections based on the bony landmarks of anterior superior  iliac spine, as well as the pubic tubercle, and identifying the femoral artery, and identifying  these nerves in relation to these structures. But these landmark-based approaches can cause a significant failure rate for these injections, and there's also risk for complications.  Several perioperative studies have shown that more anesthetic dosage is required for perioperative blocks if a blind technique is used, so subsequently ultrasound-guided techniques  have been described for these blocks. If you have access to ultrasound and expertise in ultrasound,  this can be done in the office once the internal oblique and the transverse abdominus muscles are  identified. These iliohypoplastic and ilioinguinal nerves lie in the plane right in between those two  muscles, which can be targeted both at the same time. Genitofemoral nerve blocks have also been  described with ultrasound by placing the needle around the inguinal canal and the solution  injected along the spermatic cord of the round ligament. Another common nerve that is commonly  implicated in pelvic pain is the prenatal nerve. We know that it takes origin from the S2 to S4  segments of the spinal cord, and they travel below the sacrospinous ligament and along the alcox  canal, and can cause excruciating pain with sitting in the prenatal nerve distribution, and can be associated with sensory, motor, and autonomic dysfunction  because of the nature of the nerve serving all these functions. We use NANTES criteria to diagnose prenatal neuralgia. Prenatal nerve blocks can be done under blind, without any  image guidance. Predominantly, the blind techniques are performed in obstetric clinics for performing labial surgeries or complicated instrumental deliveries for which prenatal  blocks can be helpful, and the needle is guided with the help of the finger  after palpating the scale spine. I like to use the prenatal needle, which is the rocket prenatal needle that comes in with a built-in sheet, which reduces your risk of needle stick  injury. And prenatal nerve blocks can also be done under ultrasound guidance. Prenatal nerve  lives medial to the internal prenatal artery, so blocks can be done if you are comfortable  with the ultrasound in identifying these structures. Traditionally, we like to also do these procedures under fluoroscopy guidance because it's easily  available, and the landmarks are clearly defined as well for this. Getting an optimal ischial spine view would be crucial to put under nerve locks, and the  needle is advanced to the inferior aspect of the ischial spine, verified with a small amount of contrast, and the lateral view is used to confirm the presence of contrast  of the ischial spine. That also helps to confirm a good prenatal block. A long-acting anesthetic without the steroid can be used, and the sensation in the perineum  will be checked after the block to make sure that a good block has been found. So prenatal nerve blocks have been done using ultrasound, as well as without image guidance  and without fluoroscopy. The studies so far have not found a significant difference between a blind procedure versus  an ultrasound-guided procedure or a fluoroscopy-guided procedure. Ultrasound does have a significant increase in procedure time, so when there is no difference  in using ultrasound versus fluoroscopy, it tends to be no difference. So the results for prenatal nerve block can be variable because of the variable techniques and the protocols.  So previous studies have done CT-guided injections, have shown some improvement, and there's also blind injections have shown improvement.  In conclusion, prenatal nerve block has a variable response. Longer duration of symptoms predicts less response to the block.  Prenatal nerve radiofrequency ablation has been studied as well without any immediate difference, but has shown some difference in the post-RFA group at long-term follow-up.  Briefly, several other joint injections, including sacroiliac joint injections, pubic symphysis  injections, can be done based on the presenting compliant of the diagnosis because sacroiliac joints can be pain generators as well as secondary sources for pain.  So in conclusion, history and physical examinations should guide a problem-focused approach, and  when it comes to injections, we want to think inside the box after having a careful evaluation through our history and examination.  Injections can be offered in conjunction with non-invasive strategies, which may help to prevent a chronic pill with pain condition, and all these techniques can be done with  or without image guidance and can be incorporated in a wide variety of practice settings that facilitate this practice.  Thank you for your attention, and I'll pass it on to Dr. McPaul. Hello, everybody. Good morning. I'm going to be speaking to us—or good afternoon, sorry.  We're going to be speaking about interventional approaches for chronic pelvic pain. We're going to talk about some more interventional and advanced options in the event that some  of these more conservative treatments were to fail, and I have no relevant disclosures to this particular talk.  The reason that some of what you're going to hear me say today is going to be talking about doing sympathetic blocks.  The sympathetic nervous system does not innervate viscera, but the visceral afferent fibers  travel with the sympathetic fibers back towards the spinal column, going through the white ramus of the sympathetic chain and then into the dorsal root and then back into the dorsal  horn where it enters into the spinal cord. In order to block the visceral fibers, you have to block the sympathetic chain, and that's  what these neuroanatomy slides are, and you certainly can have—everybody has access to my slides, of course.  So the first block I'll talk about is the superior hypogastric plexus block. The superior hypogastric plexus is a complex network of fibers around—in front of the  sacral promontory, in front of L5 and the S1 junction. They are just below the aorta in the endopelvic fascia, and then they form a separate inferior hypogastric plexus below that.  These areas provide visceral innervations to the majority of the pelvic structure, such as the descending colon, rectum, and internal genitalia.  The ovaries, ovarian tubes, and testes are an exception. Those are innervated from higher, from T10 to T12.  They then descend down the urogenital ridge and to finally become retroperitoneal. And so for pain of the ovaries or testes, you would perform actually splanking of celiac  plexus blocks, not a superior hypogastric plexus block. And now the thing is the majority of this innervation is from the inferior hypogastric  plexus, so in essence, we're targeting the superior hypogastric plexus to block both the superior and inferior hypogastric plexus.  Here's a cartoon showing those plexuses once again, and here's a very complex interweaving of those fibers.  And just to show how complex it is and how it's really all over surrounding the aorta and the bifurcation of the aorta into the common iliac arteries.  This is done mainly for pelvic pain secondary to endometriosis, inflammatory disease, postoperative adhesions, and unresponsive cancer pain of the pelvic organs.  There are reports of blocks providing post-prostatectomy penile and urethral pain relief, but that's less studied.  Also evidence-based here is very poor, primarily based upon case series and an expert opinion. There's one exception.  De Leon Casasola's group had a 69% success rate with neurolytic, with alcohol, superior hypogastric plexus blocks in patients with severe pelvic cancer pain, with a decrease  in oral opioid consumption of 67%. There are complications, so really this should only be done by somebody who's an advanced  practitioner who's done a lot of probably a pain medicine fellowship and some training in performing these highly complicated procedures.  There could be accidental dislodgement of atherotic plaques from the iliac vessels or the aorta, intra-arterial injection of local anesthetic into the iliac vessels can  cause a seizure. You can have a retroperitoneal hematoma and very rarely a bladder puncture or urethral puncture.  One of my patients, this is a needle snaking around the front of the L5 vertebral body. Contrast is shown here in the lateral view in the front of the L5 vertebral body extending  down to the margin of the sacrum. And then here's a different patient, much lower, which is probably a better position because it's on the inferior margin of the L5 body.  Here's more contrast. After this contrast is injected, you want to see it wrapping around this way. You do not want to see it intradiscal.  Disc puncture is also a complication with this procedure, which can lead to discitis. You usually have to do it bilaterally.  With this procedure, you're usually putting 10 cc's of local anesthetic on both sides. A ganglion and par block is another block that can be done for chronic pelvic pain and  chronic pelvic visceral pain. It provides nociceptive and sympathetic fibers to the perineum and distal rectum as well  as the perianal region and some of the other regions that are listed here. They're originally described for sympathetically mediated cancer pain involving the perineum.  It's now used to treat both cancers and non-cancerous pain as well as coccydynia, which we can get into more if there are questions about that.  There are complications that can occur, rectal penetration being one, vascular injury being another. This is the way that this is done.  A needle is passed through the margin of the sacrococcygeal junction. There's a joint there that's a rudimentary joint, rudimentary disc, excuse me, and then  is injected and it should form this comma-shaped contrast pattern that distinguishes and separates the anterior portion of the coccyx and sacrum from the rectum.  That's where the injectate would be about 10 cc's of local anesthetic. You could do 5 cc's even actually in some studies and that's sufficient.  Now lastly, I'll talk about neuromodulation. Neuromodulation is a treatment for chronic pelvic pain that has been refractory, both malignant and non-malignant.  These are implantable devices. This is a generation of electrical fields between metal contacts. At this point, I think most physiatrists are aware of how this works.  I'm only going to talk about dorsal column stimulation, which is traditional spinal cord stimulation and DRG or dorsal root ganglion stimulation today.  I won't talk about peripheral nerve stimulation in the interest of time. There are so many different waveforms now for spinal cord stimulation that deserves its own lecture.  The classical waveforms, which were paresthesia based and now the non-paresthesia based ones as well.  Indications on label are chronic neuropathic pain, failed back syndrome, which is post-surgical  pain after laminectomy or other types of back surgeries, CRPS, chronic radicular pain, neuropathic pain, and angina or ischemia.  There's a high upfront cost, but many studies have shown that at two and a half years, the cost-effectiveness curves cross.  Here's that to demonstrate how the cost of SES is less than the cost of conventional management of care and care after two and a half years.  The gait control theory doesn't fully explain how spinal cord stimulation works, especially now that we use these higher frequencies that do not elicit paresthesias in the patient  in the painful areas. I'll leave it at that for in the interest of time. The studies, somebody asked in the chat about where you would put these leads.  In patients with chronic pelvic pain, if you're using traditional neurostimulation, you would  put these somewhere between T10 and T12 because that's the area where the fibers become the  most central for the pelvis for pelvic pain, and you want to be at the area where the fibers have become central as they ascend into the brain. There have been some studies on this.  They're all case series. This is a case series of six patients that Dr. Caperell's group had treated with visceral pelvic pain with SES.  You can see the VAS and their disabilities index, both were much better after about six months. There was also this study by Tate's group in 2021, there's a much more recent study.  Now this is 13 subjects, and you can see that the responder rates are very high. At 12 months, 77% are improved, and the pain reduction is 72% at 12 months as well.  This is an 11-subject study. Now the thing is that this was a mixed study. Some of them had traditional SES, some had DRG, some had a combo, so it's hard to really  make any heads or tails out of this study, but suffice it to say that 10 of the 11 patients were doing well at six months post-implantation.  That also shows pretty good benefit as well.  This is just from Tim Deere's work where he kind of showed some images, and I'm just putting this up here to show the difference in what these look like.  The stem leads are in the epidural space, in the dorsal epidural space, in the traditional spinal cord stimulator model.  In a DRG stimulator, we put them out the foramen, overlying the dorsal rig ganglion, usually two, sometimes four.  In the case of pelvic pain, the best evidence we have right now, and the best expert we have in treating pelvic pain with dorsal rig ganglion stimulation is Corey Hunter in  New York. He and his group have shown that if you do two leads for DRG stem at L1 and two at S2, that's your best chance of getting pain relief with dorsal rig ganglion stimulation.  Now my group, along with the SIS Evidence Analysis Committee and Standards Division, last year published a, well this year I guess, published a effectiveness study, which was  a systematic review on using DRG stem for chronic pelvic pain and chronic neuropathic pain of the pelvis and of the extremity.  And what we basically decided, and again I'm just going to breeze through this here a little  bit, is that the rating for use of DRG stimulation for treatment of pelvic pain is very low. Now what that means is based on the grade criteria, it's just that the true effect is  probably markedly different from the estimated effect, which means we just don't know. There aren't enough studies.  We did say that it's low but almost moderate for chronic pain of the extremity, such as CRPS, and specifically CRPS. So CRPS we have a bunch better data on.  In summary, the data on utilizing these procedures for creating chronic pelvic pain is sparse. Decisions should be made on a case-by-case basis.  These procedures are very safe and safer than surgery in the hands of the right people, and the plural of anecdote isn't evidence, so there's so much anecdote here, and there's  so much case series, but I'll tell you that I have really good success with my patients when I use these interventions, but I use my own patient selection to make sure that  they are appropriate candidates. With that, I'll turn it over to Dr. Sharma, who will speak to us about her expertise in integrated care. Hi there.  We're running a little low on time, so I'll do my best just to give you an overview of this. Our goals here are to recognize the signs of potential centralization, the importance  of the bicycle, social approach, as well as review the evidence, and also consider what patients would benefit most from this approach.  This is the biopsychosocial approach. You can see there's biological factors here, psychological factors, and social factors.  If we had more time, I'd sort of delve into this, and it is an overlap. Central sensitization, as some of the other speakers have talked about, overlaps with  other central systems, and are characterized by L-adenia and hyperalgesia. Again, in the interest of time, we'll sort of keep moving here.  There is some significant overlap with chronic fatigue syndrome, fibromyalgia, and with the regional pelvic issues as well. We'll just keep moving here.  I do want to make sure we get time for this slide. These are sort of some of the integrative and lifestyle medicine factors we can address  that can sort of help with pain and inflammation for lots of conditions, including pelvic pain. I do want to mention here, addictions can be food, addictions can be alcohol, it can  be money, it can be gambling, it can be a lot of things. This is the SAD diet, right? The standard American diet is very SAD.  It's a lot of processed food, artificial ingredients, unhealthy fats, and it's a lack of vegetables and fruits.  This leads to ongoing inflammation, ongoing pain, longer recovery times from injuries, more flares, and not a great body mass.  This is a chronic pain food pyramid, and there's actually data on this. It parallels a Mediterranean diet pretty well.  You can start at the bottom, which is the water, and then we do vegetables and fruits.  I want to do low glycemic index foods, use extra virgin olive oil, and sort of work your way up. A big protein source here is going to be legumes and fish.  I like this one better because it actually shows something that's really important with any biopsychosocial approach to pain, which is to be physically active and to have social  connection. So all of the things matter when we're taking this approach with our patients, not just the food. I'm not a big supplement person. I really think it's food first.  They have better absorption. They make people not dependent on pills, and in some ways, they're literally just a drop in the bucket.  So we want to make sure that overall we're changing the way people eat and not just throwing supplements at them.  In terms of supplements that have been studied for pelvic pain, here's a list of the top ones that have been most explored.  The best evidence is for curcumin, also known as part of the ingredient of turmeric. And there's some data for these other ones and some research on cannabis as well.  This is a study done through the military, and so they don't mess around. And this is for musculoskeletal pain, but there's a lot of overlap.  And these were the top supplements that they recommended. And again, you can see the turmeric come up here as well.  In terms of a biopsychosocial approach, aside from nutrition, there's also mind-body approaches,  including a lot of things my colleagues have talked about here already in terms of physical  therapy type modalities, potential osteopathic benefit, potential massage benefit as well. Cognitive behavioral therapy, the idea is to decrease some of the central sensitization  and stop the sympathetic overload. And it can really help with some of the long-term outcomes.  It's really about working on coping skills, mood management, stress reduction, and social support.  This is a study of over 30 randomized controlled studies, and there was clear effect for chronic  pain, just chronic pain in general, including the kind of pain we're discussing today for depression and quality of life.  This is for psychological stress and wellbeing in general, and it's shown to decrease pain, anxiety, and depression.  This is one of my favorite studies because these people took part in two-hour group session for eight weeks, and they found a year later, they still had improvements.  So dedicating, just doing eight weeks, two hours a week, and then doing your own practice can actually lead to significant improvement in pain.  And that's for mindfulness-based stress reduction and cognitive behavioral therapy. Interestingly enough, the mindfulness-based stress reduction actually scored higher and  had more improvements. Acupuncture, you know, there's a lot to go into the mechanism of acupuncture, which unfortunately I really don't have time for right now.  I do want to share this picture because I think it's really interesting. And it's this theory on some overlap between acupuncture points, myofascial trigger points,  and fibromyalgia tender points, which were previously used. So there is some evidence for this for different types of pain. And there's also some evidence for auricular acupuncture.  In terms of mind-body interventions, yoga, tai chi, reiki, qigong, they all have some benefits, especially for chronic pelvic pain. There's definitely some evidence for yoga.  So bottom line, who can benefit? Pretty much all patients with chronic pelvic pain and chronic pain can benefit from a psychosocial approach.  Most patients even with subacute pain can benefit from this approach as a supplement to the other treatments you're doing to prevent it from becoming a chronic issue.  And I think it's important to keep in mind that this is a team approach. We can't do it all. It's great if you can work with a dedicated physical therapist trained for pelvic pain,  a dietician who works with an anti-inflammatory approach, to have patient education resources,  possibly a support group, maybe include their family if they are open to it for family support.  And then CBT, like we talked about, lifestyle modifications, medications if needed, and interventional procedures if needed.  This is a model on the right side of the program I just started, focusing more on orthopedic  pain, but it's sort of a similar concept of focusing on a lifestyle and integrative approach  and really looking at the whole person and understanding how this pain is affecting their life and that we really have to address multi-facets of their life.  So on that, I will leave it and hand it back to the rest of the faculty. Thank you so much.  Thank you, everyone. That was really nice. I'm sorry. There's always a lot of information to cover, and there's not enough time for this public meeting. Sorry, Dr. Nagpal and  Dr. Sharma, you had to rush through your presentations. But hopefully, we have all this handouts so  people can reach out to us if they have any questions. And I don't see, I think Dr. Benazir answered a couple of questions as we went through. And I don't think there was any other  question that I see.  There was a couple of questions on whether EMGs are helpful, but do you have any thoughts on that, Dr. Nepal, on your pelvic pain patients?  Do you find any use for pudendal nerve EMG studies? One of the questions was, it was used in the past mainly for research, but not sure if anyone is using for clinical practice  right now. No, there's not great, valid. I agree with what Dr. Bennett said. There's not great validated nerve conduction studies or EMG really for ascertaining  whether somebody has a pudendal neuropathy or any of these other nerves. I mean, there are described ones, but they're not very good.  In our institution now, we have pretty good radiologists and access to MR neurography, which has been a really great change in our practice.  You know, there's so few changes in practice that happen, right? So, but over the last five years, that's been a big difference for us  because the MR neurography is able to determine if there's an entrapped nerve specifically from the lumbar or sacral plexus as it emanates from those plexi.  So, I think that that's been a big change for us, and that's a much better and less invasive test, I think, than an EMG would be.  Now, I agree with everything Dr. Bennett's typed, though, about the fact that, you know, if you're trying to distinguish a radiculopathy, you may be, an EMG may be helpful.  Hi. There was one question about a patient presenting with clitoral tingling, and they were asking for how do you evaluate for this? I think it could be epidermal nerve irritation  that causes pain in that area or symptoms in the area, so a proper musculoskeletal and neurological exam might help to evaluate for that. If you have any other things to add.  I think that's it. I think we don't have, I don't see any other questions that people are waiting for an answer for, so I guess we will, oh, there is one.  For pudendal and peripheral injections, I used fluoroscopy and sensory motor stimulation, respectively, to identify the nerves. That was an answer from one of the attendees.  All right, I think we can probably end the session if there's no other questions. Thank you, everybody. Yeah, thanks, everyone. Thanks, everybody.

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