Endometriosis
This case report describes the treatment of pain due to endometriosis adhesions in a 29-year-old patient receiving pharmacological therapy.
  • In Italy, endometriosis affects 10 to 15% of women of reproductive age and 30 to 50% of infertile women or women who have trouble getting pregnant. There are at least 3 million women who have been diagnosed with endometriosis in the country. The peak incidence is between 25 and 35 years of age, although this condition may occur in lower age groups.
  • Endometriosis is a female condition caused by the abnormal growth of endometrial cells outside the uterus. It’s a chronic inflammatory condition that manifests with severe pain and bowel issues. The misplaced endometrium acts like physiological endometrial tissue (which lines the uterus). Therefore, once a month, it breaks down and bleeds, affected by the menstrual cycle’s hormonal changes.
  • Unlike menstrual blood, which flows out of the vagina, the blood from ectopic endometrial lesions has no way out. It tends to build up and inflame the surrounding areas. This may lead to the formation of endometrial cysts or adhesions between pelvic organs.
  • Endometrial adhesions are bands of fibrous scar tissue that cause different parts of an organ or adjacent organs or tissues to stick together. Adhesions restrict normal movement of the structures involved, causing tension and pain.

Endometriosis anatomia

Sex: female
Age: 29
Profession: unemployed. She had to leave her job because of her painful condition. In the past 4 years, she had to undergo pelvic surgery several times due to an entrapped bilateral inguinal hernia and a sacral cyst. The patient suffers from pelvic pain and is now receiving pharmacological treatment for endometriosis. She is an anxious patient. 

During the first examination, the patient was very anxious and worried about her situation. The severe pain had forced her to leave her job as a shop assistant. She was single and couldn’t have intercourse because of the pain. The patient had tried several treatments, but with no results; therefore, she had abandoned them all, except for a monthly session with an osteopath. These sessions – which consisted in exercises to activate and relax her lower limbs – had given her temporary relief. She felt continuous and severe spontaneous pain in the lower abdomen, especially on the left-hand side. The pain radiated bilaterally to the groin and on the left to the adductor muscle. 

The patient reported a VAS pain score of 9/10 at rest, 10/10 on palpation, and 10/10 after medium physical exertion.

The patient’s gynaecologist had identified a pharmacological therapy that stopped the active phase of endometriosis and improved its symptoms. Working locally on the inflammation and the adhesion of the uterosacral ligaments, and reducing pelvic floor muscle tension was the suggested course of action. We agreed with the gynaecologist and decided to combine an instrument-assisted anti-inflammatory therapy and manual therapy with muscle relaxation techniques. The gynaecologist would see the patient after 10 sessions.

Intimity fisiowarm manipolo

The patient had given her pain a VAS score of 10/10. The pain was spontaneous and radiated bilaterally to the groin and on the left to the adductor muscle. In a modified lithotomy position, the spontaneous pain decreased to 9/10, and its radiation to the left leg decreased too. The patient had hyperpigmentation on her abdomen and proximal lower extremity, which she reported was from a hot-water bottle.

She was tense and stiffened at the slightest contact with the abdomen. However, the pain didn’t worsen on palpation. In the vestibular area, the perineal muscles appeared slightly reddened and sore on palpation. An internal examination showed that the muscles – and especially the pubococcygeus bilaterally and the left internal obturator muscle – were tense and sore. The patient stiffened and reported unbearable pain (10/10 VAS pain score) on palpation of the uterosacral ligaments.

We suggested tecar therapy once a week with a Fisiowarm 7.0 unit associated with manual therapy and exercises to do at home. Tecar therapy was chosen with the treating physician because it offered the possibility of using the Intimity probe in superpulsed mode. The superpulsed mode allows for a significant anti-inflammatory effect, thereby speeding up catabolite removal without generating a thermal effect. The Intimity probe helps convey the energy to a specific point where the physician has indicated an endometriosis adhesion. We placed the plate in the lumbosacral area to ensure even greater precision in targeting the uterosacral ligaments. To reduce the contact surface with the Intimity probe, we covered it with a nitrile glove’s tipless finger. In superpulsed mode, the frequency is 400 kHz, and the power is set to 22Vrms to avoid the thermal effect. This is because there are no thermoreceptors in the intracavitary structures; therefore, we cannot rely on the heat sensation perceived by the patient. The treatment involved a relatively small area without movement, so it took no more than 5 minutes per side. Moreover, we taught the patient a few breathing relaxation techniques and perineal massage techniques to do at home every day, using a specific oil.

Goal 1: reducing pain and muscle tension in the structures involved (pelvic floor muscles, diaphragm, adductors, and psoas muscle).

We carried out a cycle of 4 sessions to achieve this goal.

During these sessions, the patient was in a supine position with bent legs and feet resting on supports.

The plate was positioned in the lumbosacral area. The Intimity probe – inserted in a tipless nitrile glove and covered with conductive gel – was fixed on the right-hand uterosacral ligament. After a few minutes, the patient reported an improvement in the symptoms compared to the beginning of the treatment. However, we completed the treatment after 5 minutes, as scheduled. We repeated the same treatment on the left-hand uterosacral ligament. The pain subsided on this side too. Upon completing the tecar therapy treatment, we started with the breathing techniques to reduce general and local tension. The patient also agreed to a local massage.

After 4 sessions, the patient reported an overall improvement in the symptoms. Although the initial assessment may have been affected by the patient’s anxiety (which may have increased her pain perception), the VAS score after the treatment showed a substantial improvement when at rest, which continued even after physical exertion.

    VAS score before the treatment VAS score after the fourth session
Spontaneous pain         9-10          4
Post-exertional pain           10           8
RH probe point           10            6
LH probe point           10            4

Goal 2: increasing perception and further reducing inflammation

Based on these results, we decided to carry out a second cycle to further improve the inflammation and increase pelvic floor muscle perception. We told the patient to avoid intense physical activity, such as running or going to the gym. Based on her indications, we agreed on walks, gradually increasing the distance once we verified that they did not increase pain.

We decided on a two-session cycle to achieve the desired result.

The conditions were the same as in the previous cycle: patient in a supine position with flexed knees and feet resting on supports, plate on the lumbosacral area, and Intimity probe covered with a tipless nitrile glove. The treatment in superpulsed mode lasted 5 minutes for each ligament (frequency: 400 kHz; power: 22Vrms).

Tecar therapy was followed by breathing techniques and a perineal massage to promote global and local muscle relaxation. The patient also did some exercises to increase pelvic muscle perception.

Before starting the fifth session, the patient reported some anxiety due to a new job opportunity. Her inability to control anxiety had made her even tenser and had led to gastrointestinal problems, difficult bowel movement, and losing the progress made. Even the muscles were tenser compared to the last session. However, the patient reported that, before receiving the news that caused her anxiety, she had taken longer walks (up to 20 minutes) increasingly without any discomfort.

 

  VAS score before the 5th session VAS score after the 6th session
Spontaneous pain               7              6
Post-exertional pain               8              6
RH probe point               6              4
LH probe point              6              4

Goal 3: further reducing inflammation and controlling muscles during movement.

The results achieved with the previous cycle indicated a gradual improvement of the inflammation and adhesions between the uterosacral ligaments. Symptoms also improved slightly at rest and after exertion. The patient’s psychological state had an impact on her muscles and her ability to relax. That’s why we suggested a few psychotherapy sessions, which, however, she refused.

During this stage, we used tecar therapy to work on the inflammation, manual therapy to relax her muscles, and physical exercise to increase her perception of the pelvic floor muscles during active movement.

We carried out a cycle of 4 sessions to achieve this goal.

  VAS score before the 7th session VAS score after the 10th session VAS score after one week without treatment
Spontaneous pain          5              1             2
Post-exertional pain         5             3            2
RH probe point         3            2             2
LH probe point        4            3            3
tecarterapia manipolo intimity

Using the Intimity probe during the treatment proved to be extremely effective on the inflammation, as it allowed for conveying the current to the specific endocavitary area affected by the condition. In this particular case, there were some ups and downs in the results, mainly due to the patient’s psychological state. However, these ups and downs mainly affected the muscles. The area treated with tecar therapy had a much smoother course. The patient was happy with the results. Now, she can walk even for 45 minutes and do the simple muscle activation exercises she learned during the sessions without feeling pain. She will gradually resume guided physical activity and undergo maintenance and follow-up sessions once a month.

 

Simona Colicchia
Physiotherapist, Expert in Pelvic Floor Rehabilitation, Diastasis Recti, and Physioaesthetics.
Specialised in Global Postural Rehabilitation

 

 

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