"I wish I knew then what I know now" - pain science education concepts important for female persistent pelvic pain: a reflexive thematic analysis.

ABSTRACT: Pain science education (PSE) provides people with an understanding of "how pain works" grounded in the biopsychosocial model of pain; it has been demonstrated to improve outcomes in musculoskeletal pain conditions. Preliminary evidence suggests PSE may be effective for female individuals with persistent pelvic pain, but how the content of PSE needs to be modified for this group remains to be determined. A reflexive thematic analysis of qualitative data was performed to identify PSE concepts that female individuals with persistent pelvic pain consider important and why. Twenty individual, semistructured interviews were conducted with adult females who had engaged with PSE and had self-identified as having "improved" pelvic pain. Most participants had been diagnosed with endometriosis (n = 16). Four themes were generated capturing PSE concepts considered important by female individuals with "improved" pelvic pain: (1) "A sensitised nervous system leads to overprotective pain" validated their pelvic pain as being real; (2) "Pain does not have to mean the body is damaged (although sometimes it does)" provided reassurance that pelvic pain does not mean their condition is worsening; (3) "How I think, feel, and 'see' my pain can make it worse" enabled participants to find optimal ways to manage their pain; and (4) "I can change my pain… slowly" provided hope that pelvic pain can improve and empowered them to pursue pain improvement as a viable goal. This study generated 4 PSE learning concepts that were important to female individuals with improved pelvic pain and may be incorporated into PSE curricula for female individuals with pelvic pain.

Clinical assessment and management of vaginismus.

BACKGROUND: Vaginismus is one of the leading causes of painful sex (dyspareunia) for women. General practitioners (GPs) play a vital role in diagnosing and treating vaginismus, as well as coordinating a multidisciplinary team to support people with vaginismus. OBJECTIVE: The aim of this article is to summarise what is currently known about vaginismus, including its aetiology and contributing factors, how a diagnosis can be made, the implications of vaginismus on primary care clinical practice and the available treatment options for people with vaginismus. The article focuses on treating vaginismus exclusively, where other possible medical causes or comorbidities have been examined and excluded (eg vulvodynia). DISCUSSION: GPs play a vital role in helping people recover from vaginismus through validating people's experiences, making an accurate diagnosis and making referrals to other relevant health professionals. GPs can also offer a range of treatment options for people with vaginismus. While the management of vaginismus can be time-consuming and take some trial and error, multidisciplinary care with multimodal therapy often results in positive patient outcomes.

Recommendations for patient education in the management of persistent pelvic pain: a systematic review of clinical practice guidelines.

ABSTRACT: Patient education has a critical role in the management of pain. There is considerable heterogeneity in patient education for females with persistent pelvic pain (PPP), and it remains unclear what is considered best clinical practice. Therefore, this systematic review identified and summarised recommendations for patient education in the management of benign gynaecological and urological conditions associated with PPP, as endorsed by international guidelines. Academic and relevant guideline databases were searched from inception to May 2022. Included guidelines were those for the management of benign gynaecological and urological conditions associated with PPP in adult females published in English, of any publication date, and endorsed by a professional organisation or society. Two independent reviewers screened 3097 records; 17 guidelines were included in the review. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. Recommendations were pooled using descriptive synthesis. Persistent pelvic pain guideline quality was generally poor. Three guidelines were classified as "excellent" (The NICE, RANZCOG, and ESHRE endometriosis guidelines) and therefore recommended for use. Eleven guidelines (64.7%) recommended patient education for females with PPP. Recommendations for education content were variable, however most frequently covered treatment strategies and pelvic pain diagnoses. For education delivery, the most frequent recommendations were for support groups and written/printed materials. Further research into tailored education interventions is needed for females with PPP.

The Efficacy of Self-Management Strategies for Females with Endometriosis: a Systematic Review.

Self-management is critical for the care of endometriosis. Females with endometriosis frequently use self-management strategies to manage associated symptoms; however, the efficacy of such strategies is unknown. The aim of this review was to systematically appraise the evidence concerning efficacy of self-management strategies for endometriosis symptoms. Electronic databases, including Medline, Embase, Emcare, Web of Science Core Collection, Scopus, and the Cochrane Central Register of Controlled Trials, were searched from inception to March 2021. We included peer-reviewed experimental studies published in English evaluating the efficacy of self-management strategies in human females laparoscopically diagnosed with endometriosis. Studies underwent screening, data extraction, and risk of bias appraisal (randomised studies: Risk of Bias 2 tool; non-randomised studies: Risk Of Bias In Non-randomized Studies - of Interventions tool). Of the fifteen studies included, 10 evaluated dietary supplements, three evaluated dietary modifications, one evaluated over-the-counter medication, and one evaluated exercise. Most studies had a high-critical risk of bias. Many self-management strategies were not more effective at reducing endometriosis symptoms compared to placebo or hormonal therapies. Where studies suggest efficacy for self-management strategies, no recommendations can be made due to the poor quality and heterogeneity of evidence. High-quality empirical evidence is required to investigate the efficacy of self-management strategies for females with endometriosis.

Ultrasound Characteristics and Scanning Techniques of Uterosacral Ligaments for the Diagnosis of Endometriosis: A Systematic Review.

Endometriosis is a common and painful gynaecological condition that takes an average of 6.4years to diagnose. While laparoscopic surgery is the recommend gold standard in diagnosis of endometriosis, transvaginal ultrasound (TVS) is able to assist surgeons in the planning and management of patients, especially when there is limited visualisation in the posterior compartment. Uterosacral ligaments (USL) are located in the posterior compartment and are one of the first and most common places that endometriosis deposits, The International Deep Endometriosis Analysis (IDEA) group consensus, which are the current guidelines for DE imaging, recommends a thorough ultrasound assessment to identify endometriotic disease. This includes an assessment of anatomic structures in the posterior compartment including the USLs. However, IDEA does not explicitly articulate specifics of USL imaging and measurements on ultrasound. The primary aim of this review is to determine is to identify ultrasound techniques and characteristics of USLs in the diagnosis of deep infiltrative endometriosis (DE). The secondary aim is to describe and summarise these findings into normal and pathological findings. A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A population, interventions, comparator, and outcome framework was used to define a search strategy. Articles were screened using Covidence review management system, and data was extracted by two authors using a standardised and piolet-tested form. Quality assessment was conducted using the Critical Appraisal Skills Programme (CASP). Medline, Embase and Scopus and Google Scholar were searched yielding 250 articles, with 22 being included in the review. Analysis of the data demonstrated inconsistent reporting of ultrasound techniques and characteristics of USLs. Most (20/22) papers described abnormal criteria of USLs, only 5/22 papers determined what the normal USL appearance is or what techniques (11/22) were applied. Even though reporting was heterogeneous, there was a high level of tertiary centre participation with gynaecological experienced operators, therefore was a high level of agreement. Through review of the current literature, this study has investigated ultrasound techniques and characteristics of USLs for the diagnosis of DE. All papers included in this review reported presence of pathological sonographic findings of the USLs when DE was presented therefore it is recommended that USL examination become a part of TVS exams when DE is clinically suspected. This study also demonstrated that there was lack of data and no agreement when it comes to measuring USLs with DE. Even so, the current evidence demonstrates that scanning the USLs, and locating, identifying, and describing USL thickening and endometriotic nodules in the various locations using the described techniques and characteristics in this review has clinical value in early diagnosis.

The Influence of Stress on Student Performance during Simulation-based Learning: A Pilot Randomized Trial.

Background: Simulation-based learning is an important educational medium that is being implemented increasingly for the purpose of improved patient care and safety. However, there is evidence to suggest that simulation-based education (SBE) may increase anxiety, as illustrated through self-reporting and physiological responses. Despite such data, no studies have investigated whether anxiety and stress can be manipulated through SBE scenario design and delivery to facilitate optimal learning conditions. Objective: This pilot study examined perceived anxiety and physiological stress experienced by entry-level physiotherapy students while learning a skill using SBE and the relationship between this anxiety and their subsequent skill performance. Methods: Final-year physiotherapy students were randomly allocated to one of three SBE experiences: low, medium, or high stress. The experiences were designed to induce increasing levels of stress and anxiety. Performance of the learned skill (endotracheal airway suctioning) was measured after the SBE using a bespoke assessment form. Cortisol levels, heart rate, and perceived anxiety measurements (State-Trait Anxiety Inventory and visual analog scale) were also collected. Results: Twenty-seven participants completed the trial. There were significant differences in perceived stress and physiological response between the groups. The low-stress group demonstrated significantly better performance of airway suctioning than the higher-stress groups (P = 0.02). Higher anxiety was correlated with poorer skill performance (r = -0.410). Conclusions: Students report SBE to be stressful, and scenarios themselves can influence the stress and anxiety experienced. Greater stress is associated with poor learning outcomes during SBE. Healthcare educators involved in SBE scenario design need to consider the stress levels experienced. Future research to determine optimal stress and embed measurement of stress in SBE experiences is warranted.

The accessibility of pelvic health physiotherapy for adolescents with persistent pelvic pain: a qualitative framework analysis.

BACKGROUND: Physiotherapy, with a specific focus on pelvic health, is one service used in the multidisciplinary management of adolescent persistent pelvic pain (PPP). However, there has been little investigations into the accessibility of physiotherapy for adolescents with PPP. OBJECTIVE: This qualitative study aimed to detail the experiences of adolescents with PPP accessing a tertiary hospital physiotherapy service. METHODS: Two focus groups included six adolescent females diagnosed with PPP that had either a) been referred and attended the physiotherapy clinic (n = 5), or b) been referred to physiotherapy but yet to attend their appointment (n = 1 plus one support person). Focus group transcripts were deductively thematically analyzed according to four domains from the patient-centered healthcare accessibility framework. RESULTS: The domain of 'Approachability and ability to perceive' was impacted by limited information and poor patient health literacy. 'Acceptability and ability to seek' was hindered by adolescent mental health struggles and failures of previous PPP management. 'Availability and accommodation, and ability to reach' was influenced by lengthy referral processes, and reliance on familial support for transport. 'Acceptability and ability to engage' was facilitated by engaging clinicians and group environments, however, adolescents became dependent on physiotherapy for pain management. CONCLUSION: Physical, social, and environmental factors influence the accessibility of physiotherapy for adolescents with PPP. Healthcare services should consider the specific needs of adolescents with PPP for optimizing accessibility.

The relationship between symptom severity, bother and psychological factors in women with pelvic organ prolapse: A cross-sectional observational study.

AIM: The primary aim is to explore the relationship between symptom severity and prolapse bother in women with pelvic organ prolapse (POP). The secondary aim is to determine the association between psychological variables and prolapse bother. METHODS: A cross-sectional observational study was conducted via online surveys assessing POP bother (visual analog scale for bother), POP symptom severity (International Consultation on Incontinence Questionnaire-Vaginal Symptoms), and psychological measures of depression and anxiety (Kessler psychological distress scale [K-10]), catastrophizing (modified pain catastrophizing scale [mPCS]), and self-efficacy (modified pain self-efficacy questionnaire [mPSEQ]) in women with self-reported POP. Symptom severity, bother and psychological variables were analyzed using linear regression. RESULTS: Seventy-six women with a mean (SD) age of 42.8 (14.57) years were included in analysis. A moderate to strong positive linear relationship (R2 = 0.449, p < 0.001) was found between symptom severity and POP bother. Prolapse bother and psychological variables were moderately correlated, where increased K-10 scores (R2 = 0.230, p = 0.001), higher mPCS scores (R2 = 0.460, p < 0.001), and lower mPSEQ scores (R2 = 0.460, p < 0.001) were associated with increased POP bother. Moderate and severe catastrophizing was associated with significantly higher POP bother, with mean POP bother scores of 7.861 ± 0.45 (p < 0.001) and 8.652 ± 0.45 (p < 0.001), respectively. CONCLUSION: A moderate positive relationship between POP bother and symptom severity was found, with greater psychological distress and lower self-efficacy associated with increasing POP bother. Women presenting with POP should be screened for psychological factors to guide management.

Development of a multinational, multidisciplinary competency framework for physiotherapy training in pessary management: an E-Delphi study.

INTRODUCTION AND HYPOTHESIS: Vaginal support pessaries are intravaginal devices designed to relieve symptoms of pelvic organ prolapse, but they can cause serious medical complications if not managed well. Physiotherapists are well placed to manage pessaries, but there are no guidelines on the training required for competency in pessary management (PM). METHODS: A scoping review of current literature on PM training was conducted to develop draft competency standards, which were reviewed by a multidisciplinary focus group. Using e-Delphi methodology, a multidisciplinary and multinational expert panel then refined the standards. Three rounds of e-Delphi online surveys were conducted, with individual participant feedback and one videoconference to discuss items that did not reach consensus. Consensus was set at 80% agreement and stability measured using kappa coefficient. RESULTS: Pessary training competency standards, developed by 29 experts, covered three key domains including: (1) prerequisite knowledge and understanding; (2) entrustable professional activities; (3) pessary-specific standards under ten key roles. Consensus was reached on all 73 (100%) competency standards and stability demonstrated for 95.9% of standards. There was no attrition of expert panel participants through the e-Delphi rounds. CONCLUSIONS: This e-Delphi study provides the first, robust recommendations on training standards for physiotherapists in PM. These competency standards will provide clinicians with a self-assessment tool, and educators and training institutions with a benchmark in training for PM, which should improve options and reduce risk for women with prolapse being managed with a pessary.

Health seeking behaviours and treatments received by Australian women with vulvodynia: A cross-sectional survey.

BACKGROUND: Vulvodynia is a condition characterised by pain in the vulva lasting more than three months and for which no obvious aetiology can be found. It affects around 8% of women and has significant negative impacts on quality of life. There is a paucity of research on healthcare management pathways and the use of evidence-based treatments in an Australian community setting. AIMS: To explore which healthcare professionals Australian women with vulvodynia seek treatment from, and which treatments are recommended, provided, or prescribed by these healthcare professionals. MATERIALS AND METHODS: A cross-sectional online survey was conducted from May 2019 to August 2019. Women were eligible to participate if they had been diagnosed with vulvodynia by a healthcare professional, were currently living in Australia, and were over 18 years old. RESULTS: Fifty respondents meet the inclusion criteria, with a mean age of 30.5 years. On average, respondents reported seeing four different types of healthcare professionals in the management of their vulvodynia, with general practitioners (GPs) (98%), medical specialists (96%), and physiotherapists (80%) being the three most commonly consulted. Most respondents reported seeing multiple GPs (>87%), multiple medical specialists (>77%), and multiple physiotherapists (50%). The most commonly prescribed interventions were pelvic floor down-training exercises (76%), topical (70%) and oral (70%) medication, and vulvodynia information (56%). CONCLUSIONS: Australian women with vulvodynia seek help from several professionals and receive a variety of treatments for their pain. Of concern is many treatments that are being offered clinically have very little peer-reviewed evidence of effectiveness in vulvodynia.

Labour induction massage: A thematic content analysis of Australian massage therapists' website pages.

BACKGROUND AND PURPOSE: There is limited evidence on the efficacy and safety of induction massage; however, there are some massage therapists in Australia who offer induction massage. The aim of this paper is to determine the information being provided to consumers on websites pages of Australian massage therapists who provide 'induction massage'. MATERIALS AND METHODS: A qualitative summative content analysis methodology employing both manifest and latent content analysis was used to examine website pages of Australian massage therapists offering 'induction massage'. RESULTS: Twenty-eight websites met the criteria for inclusion. The qualitative theme was a façade of hope with three subthemes: a) misconception and equivocation, b) marketing scieneploitation and c) lack of empowerment. CONCLUSION: While there were only a small number of websites that provided induction massage, these webpages generally failed to provide accurate and complete information and used deceptive and misleading statements and language that made 'induction massage' appear more efficacious and legitimate than current evidence suggests it is, thus potentially giving false hope to potential consumers.

How Might We Screen for Psychological Factors in People With Pelvic Pain? An e-Delphi Study.

OBJECTIVE: Persistent pelvic pain (PPP) is a complex condition often influenced by psychological factors that can alter treatment outcomes. These factors are potentially modifiable; however, currently there is no instrument to screen for them. The purpose of this study was to determine: (1) which psychological factors should be screened in individuals with PPP, and (2) the most appropriate statements to represent these psychological factors. METHODS: The study used a focus group design followed by an electronic-Delphi (e-Delphi) process. A focus group consisting of 8 experts was conducted to determine the relevant psychological factors to screen. These results informed round 1 of the e-Delphi process, consisting of a panel of 14 pain/pelvic pain experts. The e-Delphi process consisted of 3 rounds of online surveys and 2 teleconference discussions to establish consensus on the most appropriate statement to screen for each of the psychological factors. RESULTS: The focus group identified 13 relevant psychological factors. During the e-Delphi process, relevant screening statements were assessed using a 100-point allocation system. Experts could reword and suggest new statements. Statements were assessed for consensus and stability and were eliminated as the rounds progressed if they met the exclusion criteria. At the termination of round 3, there were 15 statements remaining. CONCLUSION: The final list of 15 statements will assist clinicians in screening for psychological factors and is an important step for clinicians in providing psychologically informed care to people with PPP. Future research should determine the psychometric properties of the statements to determine their clinical utility as a questionnaire. IMPACT: This study has refined a list of statements to help screen for psychological factors in individuals with PPP. Developed robustly using an e-Delphi method, this list is an important first step forward for clinicians to provide psychologically informed care to these individuals.

Interrogating cortical representations in elite athletes with persistent posterior thigh pain - New targets for intervention?

OBJECTIVES: Hamstring injuries in athletes can lead to significant time away from competition as a result of persistent posterior thigh pain. These cases are often difficult to treat as the state of the tissues alone cannot explain symptoms. In non-athletic populations with persistent pain, disruptions to tactile, proprioceptive, and spatial cortical representations exist, which has led to promising brain-based treatments. Here, we explored whether athletes with persistent posterior thigh pain also display impairments in these cortical representations. DESIGN: Cross-sectional study. METHODS: Fourteen male professional athletes with persistent posterior thigh pain ('Patients') and 14 pain-free age, sport, body mass index and level-matched controls ('Controls') participated. The tactile cortical representation was assessed using two-point discrimination (TPD) threshold and accuracy of tactile localisation; the proprioceptive cortical representation was assessed using a left/right judgement task; spatial processing was assessed using an auditory detection task. RESULTS: TPD thresholds were similar for Patients and Controls (p=0.70). Patients were less accurate at localising tactile stimuli delivered to their affected leg, slower to make left/right judgements when the lower limb image corresponded to the side of their affected leg, and less accurate at detecting auditory stimuli delivered near their affected leg, when compared to their healthy leg or to the leg of Controls (p<0.01 for all). CONCLUSIONS: Leg-specific tactile, proprioceptive, and spatial processing deficits exist in athletes with persistent posterior thigh pain. That these processing deficits exist despite rehabilitation and normal tissue healing time suggests they may play a role in the persistence of posterior thigh pain.

The Prevalence and Educational Impact of Pelvic and Menstrual Pain in Australia: A National Online Survey of 4202 Young Women Aged 13-25 Years.

STUDY OBJECTIVE: To explore the prevalence and impact of dysmenorrhea, pelvic pain and menstrual symptoms on young women at school or in tertiary education. DESIGN AND SETTING: Cross-sectional online survey in Australia. PARTICIPANTS: A total of 4202 adolescent and young women (13-25 years of age; median age 17 years), having reached menarche, living in Australia and currently attending school (n = 2421) or tertiary education (n = 1781). INTERVENTIONS: Online survey hosted by Qualtrics between November 2017 to January 2018. Data were collected on sociodemographic data, menstrual cycle characteristics, dysmenorrhea, pelvic pain, and educational and social impact. MAIN OUTCOME MEASURES: Information on menstrual and pelvic pain impact, academic absenteeism and presenteeism, impact on non-academic activities and interactions with teaching staff. RESULTS AND CONCLUSIONS: Dysmenorrhea was reported by 92% of respondents. Dysmenorrhea was moderate (median 6.0 on a 0-10 numeric rating scale) and pain severity stayed relatively constant with age [rs(3804) = 0.012, P = .477]. Noncyclical pelvic pain at least once a month was reported by 55%. Both absenteeism and presenteeism related to menstruation were common. Just under half of women reported missing at least one class/lecture in the previous three menstrual cycles. The majority of young women at school (77%) and in tertiary education (70%) reported problems with classroom concentration during menstruation. Higher menstrual pain scores were strongly correlated with increased absenteeism and reduced classroom performance at both school and in tertiary education. Despite the negative impact on academic performance the majority of young women at school (60%) or tertiary education (83%) would not speak to teaching staff about menstruation.