Event 4: Treatment Goals

Overall Treatment Goals

• Improve quality of life
• Improve functional status
• Decrease pain

Therapeutic Goals

• Identify and treat physical and psychological morbidity
• Assist in the development of:
  • Positive coping techniques
  • Communication strategies
  • Problem solving skills
• Set realistic treatment goals: Improve quality of life
• Acknowledge and support woman
• Provide medication management
• Convene a interdisciplinary team

Test Your Knowledge: CPP Therapeutic Approaches

Name two therapeutic approaches that would help manage physical and psychological morbidity of CPP.

Treatment Modalities for CPP

Medications

Surgery

Identification of endometriosis

Treatment of endometriosis and/or infertility with ablation, lysis and excision of implants and adhesions, cystectomy of endometriomas

Uterine nerve ablation and/or presacral neurectomy for the management of dysmenorrhea has had mixed results

Reference

Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea. Proctor ML et al. Cochrane Database Syst Rev. (2005)

Physical Therapy

• Pelvic floor muscle work (physical therapist with advanced training)
  • Myofascial and trigger point release
  • Visceral fascial and joint mobilization
  • Biofeedback
  • Electrical stimulation
  • Relaxation techniques
  • Teach home exercise program
    • Abdominal breathing
    • Stretching exercises
    • Self myofascial release
    • Vaginal dilators
    • Strengthening exercises

Treatment of Trigger Points

• Ultrasound energy, manual therapy
• Local anesthetic injection
  • 93% success by 5th injection in abdomen (Kuan, 2006)
  • Lidocaine 1% x 10-15cc, bupivicaine 0.25% - 0.5% x 10-15cc

Sexual Education for Patients

• Learn about your body
  • Explore your pleasure spots
  • Educate your partner about what is pleasurable
• Connect with your partner in sexual and non-sexual ways, learn to communicate about sex
• Prepare for sex: relax the pelvic floor muscles, use lubricants, take time for arousal
• Reinvent your sex life and have fun
• Avoid painful activities

Reference

Heather Howard, PhD Sexual Rehab.org

Complementary and Alternative Treatments

• Mind/body interventions:
  • Breathing exercises, imagery, mindfulness-based stress reduction, laughter yoga, etc.
• Movement therapies:
  • Yoga, Tai Chi, Feldenkrais, etc.
• Nutrition:
  • Anti-inflammatory diet/herbs, multivitamins, B complex, fish oil, calcium/magnesium, herbal tonics or adaptogens
• Alternative providers:
  • Traditional Chinese medicine, craniosacral, chiropractic, energy medicine, strain counter strain, etc.
• Caring for the spirit:
  • Meditation, art, journaling, etc.

Psychological Support

• Evaluation of existing or pre-existing psychological issues such as PTSD exacerbated by pain
• Evaluation and treatment of anxiety and depression
• Evaluate physical effects of pain, psychological reactions to pain, behavioral thought patterns that contribute to disability, spiritual distress and lack of social support (Arnstein, 2003).
• Focus on healing the whole person, alleviating suffering, and empowering the patient with knowledge (American Holistic Nurses Association, 2010).

Services Provided by Pain Medicine

• Pudendal or hypogastric nerve blocks or ablation
• Medication management consultation
• Pain psychology: cognitive behavioral therapy, support, stress reduction strategies, etc.

Centering Model

• Emphasizes patient empowering through promotion of self-care, peer support, and group problem solving
• Each Centering group is shaped and defined by the needs, priorities, and experiences of the patients themselves
• A licensed health provider and a co-facilitator lead the group
• Formally trained in the Centering model. 

Reference

Rising, 1998.

3 Components of Centering CPP

• Health assessment: patients contribute to medical record, meet with provider each visit
• Education: facilitative leadership style, self assessment to introduce each topic, health education materials, discussion
• Support: friendships and community building fostered, share experiences and knowledge with each other

CPP Centering Topics

• Causes of CPP, anatomy, types of pain
• Easing pain and symptoms
• Myofascial pain and the pelvic floor
• Medications
• Nutrition: anti-inflammatory diet, herbs and supplements
• Setting goals
• Managing stress: mind/body modalities
• Communication: assertiveness and active listening
• Sexual intimacy: increasing pleasure and improving communication
• Spirituality: what brings hope and joy

Case Study Treatment Plan

• Education: chronic vs acute pain, CPP manifestations (endometriosis, IC, IBS, pelvic floor dysfunction, depression) and treatment modalities.
• Medication: Continuous oral contraceptives. Nightly topical 5% lidocaine to vestibule. Consider use of antidepressant such as venlafaxine for the management of depression and pain. Educate re: use of opiates may increase hyperalgesia.
• Physical Therapy: Refer to women’s physical therapist for myofascial release, biofeedback, and home exercise program. Use heat/ice and stretching.
• Nutrition: anti-inflammatory diet, herbs and supplements
• Psychology: Referred to pain psychologist for cognitive behavior therapy (CBT) and support for chronic pain.
• Sexuality education: Avoid intercourse if painful. Alternative sexual pleasuring discussed. Refer patient and partner to sexologist.
• Mind/body: purchase pain imagery CD, purchase book on managing pain, attend mindfulness based stress reduction class
• It is unlikely that surgical intervention would be recommended for this patient at this time. Rationale: last surgery did not identify pathology, patient currently not experiencing cyclic pain diagnostic for endometriosis, and the use of continuous OCs should provide adequate treatment of endometriosis.

Test Your Knowledge

True or false: Chronic pain conditions such as CPP are treated with a multidisciplinary holistic approach addressing the mind, body and spirit.