Multimodal physical therapy proves effective for women with chronic pelvic pain

Multimodal physical therapy proves effective for women with chronic pelvic pain | Image Credit: © Syda Productions - © Syda Productions - stock.adobe.com.

Multimodal physical therapy is effective in women with chronic pelvic pain (CPP), according to a recent study published in the American Journal of Obstetrics & Gynecology.¹

CPP has been linked to adverse sexual, behavioral, cognitive, and emotional outcomes. It has been estimated in 25% of female individuals, making it a significant health burden.

While CPP may be treated with conservative, pharmacological, or surgical therapies, data about the efficacy of conservative options remains lacking.² Additionally, current reviews are outdated, failing to provide a comprehensive overview.¹

Investigators conducted a systematic review to evaluate the efficacy of conservative therapies in women with CPP. The Amed, PsycINFO, CINAHL, SportDiscuss, Embase, Medline, PubMed, and Cochrane databases were assessed for articles published from inception to January 16, 2023.

Studies evaluating women with pelvic pain lasting at least 3 months without an underlying pathology were included in the analysis. Additional eligibility criteria included evaluating an intervention in a trial arm and comparing the intervention with inert or nonconservative treatment.

Conservative therapies assessed included multimodal physical therapy, predominantly psychological approaches, and other tissue-based monotherapies. Relevant outcomes included sexual measures, pain outcomes, health-related quality of life, physical and psychological function, symptom severity, and perceived improvement.

Two independent reviewers performed title and abstract screening, with disagreements resolved through discussion or by a third reviewer. A single reviewer performed data extraction, with a second reviewer verifying the accuracy of data.

Extracted data included study design, participant characteristics, intervention and control treatment details, type of conservative therapy, primary diagnosis, outcome measures used, and results. Risk of bias was assessed using the Physiotherapy Evidence Database (PEDro) scale.

There were 41 (RCTs) studies included in the final analysis, 38 of which were randomized controlled trials, 2 were follow-up studies, and 1 was a pilot study. The trials included 2168 female patients aged a mean 35.1±8.6 years. Most studies were published from 2018 onwards.

CPP was assessed in 13 RCTs, vulvodynia in 16, bladder pain syndrome in 5, dyspareunia in 2, and genito-pelvic pain and urogynecological pain each in 1. Multimodal physical therapy was assessed in 7 RCTs, predominantly psychological approaches in 10, acupuncture in 5, and tissue-based monotherapies in 18.

Pain intensity was reduced in patients undergoing multimodal physical therapy vs controls, with a standardized mean difference (SMD) of -1.69. Additionally, a mean difference of -2.87 was reported when retransforming SMD to a normal 0 to 10 pain scale. This data indicated a significant effect and had high certainty of evidence.

During follow-up, the SMD was -1.82, highlighting efficacy at 12 to 36 weeks posttreatment. This indicated a mean difference of -3.09 on a 0 to 10 pain scale.

In comparison, no significant impact on pain intensity was reported from predominantly psychological approaches, with an SMD of -0.18. For acupuncture, the SMD was 1.08, highlighting a nonsignificant effect. Similar results were reported for tissue-based monotherapies.

Sexual measures were also improved by multimodal physical therapy when compared to controls. Intercourse was attempted less often in the conservative therapy group, indicating a more flexible approach toward sexual activity.

Predominantly psychological approaches also showed a statistically significant, small effect. However, no effect was reported from tissue-based monotherapies.

For psychological function, 6 of 8 RCTs found superiority from multimodal physical therapy vs controls. In comparison, only 1 trial showed significant between-group differences from tissue-based monotherapies, and only for pain catastrophizing and pain anxiety.

These results indicated efficacy from multimodal physical therapy in managing CPP without an underlying pathology. Other conservative therapies did not show efficacy, highlighting multimodal physical therapy as the only conservative method with proven efficacy.

References

1. Starzec-Proserpio M, Frawley H, Bø K, Morin M. Effectiveness of nonpharmacological conservative therapies for chronic pelvic pain in women: a systematic review and meta-analysis. American Journal of Obstetrics & Gynecology. 2025;232(1):42-71. doi:10.1016/j.ajog.2024.08.006
2. Ghai V, Subramanian V, Jan H, Loganathan J, Doumouchtsis SK; CHORUS: An International Collaboration for Harmonising Outcomes, Research and Standards in Urogynaecology and Women’s Health (i-chorus.org). Evaluation of clinical practice guidelines (CPG) on the management of female chronic pelvic pain (CPP) using the AGREE II instrument. Int Urogynecol J. 2021;32(11):2899-2912. doi:10.1007/s00192-021-04848-1