INTRODUCTION:

A clinical condition of soft tissue pain is known as myofascial pain. It is a frequent cause of Chronic Pelvic Pain (CPP) that is both undiagnosed and mistreated. Women who experience chronic pelvic discomfort may have Myofascial Pelvic Pain Syndrome (MPPS).

Pelvic discomfort is a typical symptom of MPPS, therefore most CPP have some degree of it^1,2. 20% of women with the condition never undergo any type of research to determine the source of their pain, and about 60% of those with the disease never receive a precise diagnosis³. Although there is no laboratory or imaging test that can validate the existence of an MTrP, reliable clinical criteria have been created to identify a trigger point. These include the following: A tangible taut band, a nodule in the band that is excruciatingly sensitive, and a reproduction of the women's pain with pressure on the tender nodule and (d) uncomfortable stretch limit or complete range of motion⁴. Myofascial pain disorders are typically treated with this sort of bodywork, also known as trigger point therapy or myofascial release⁵. Fundamentally, physical therapy involves analytical and global treatments, such as phonophoresis with painkilling gels, massage, stretching, release of trigger points by acupressure, and dry needling to alleviate mobility restrictions in the fascias⁶.

In order to relieve pain and restore motion, myofascial release is a safe and very effective hands-on method that entails applying gentle sustained pressure into the myofascial connective tissue limitations⁷. Myofascial release (MFR) is a type of manual treatment that works to return the myofascial complex to its ideal length, lessen discomfort, and enhance function by applying a low load, prolonged stretch⁸. Deep tissue mobilisation methods such stripping, strumming, skin rolling, and effleurage, as well as voluntary contraction and release/hold-relax/contract-relax/reciprocal inhibition, were employed in conjunction with MRT⁹. The pelvic floor muscles can be contracted and relaxed to govern bowel movements, urine, and, for women in particular, sexual activity¹⁰. Numerous factors can weaken the pelvic floor, including carrying the uterus throughout pregnancy, giving birth vaginally, which can strain the muscles, being overweight, coughing constantly, and having lower amounts of oestrogen after menopause¹¹. The repetitive contraction used in pelvic floor workouts increases muscular tone and strength. The strength and intensity of the muscular contraction will determine how effective the exercises are performed¹². The individuals also receive phonophoresis utilising ultrasound while having Diclofenac gel applied to the painful area. The present study was under taken with the intention to find out the effectiveness of myofascial release and pelvic relaxation exercise combined with phonophoresis using ultrasound with Diclofenac gel in subjects with myofascial pelvic pain syndrome.

METHODOLOGY:

20 participants took part in this experimental investigation at the Faculty of Physiotherapy Dr. M.G.R Educational and Research Institute. The research complied with ethical standards for using humans. Before beginning the therapy procedure, the participants gave their informed consent. The study was conducted for four weeks. Using a simple random sampling procedure, subjects were chosen. Women in the age range of 25 to 40 who were diagnosed with MPPS following vaginal delivery and had symptoms lasting longer than six months met the inclusion criteria. Subjects with urogenital or pelvic infections, inflammatory diseases, tubo-ovarian abscesses, vaginitis and salpingitis, interstitial cystitis, and urological conditions were excluded from the study. Outcome measures included were visual analogue scale (VAS), Pelvic pain impact questionnaire (PPIQ), SF-36 questionnaire.

PROCEDURE:

20 subjects with myofascial pelvic pain syndrome were randomly divided into two groups. Group A (n=10) subjects were treated with myofascial therapy. Group B (n=10) subjects were treated with pelvic relaxation exercise. Both the groups received phonophoresis using ultrasound with Diclofenac gel.

Group-A (Myofascial Therapy):

Subject is in the supine lying position on the couch with both hips and knees flexed and feet placed on the wall for support. Then the hips should be abducted and the subject should hold this position for 30 seconds and sustain the pressure for about 5-7 minutes and then relax.

Group-B (Pelvic Relaxation Exercise):

For a total of 4 weeks, the individuals engaged in the activity for 30 minutes each day. The person assumes a comfortable position, either sitting with their legs crossed or lying down with their knees bent. The next instruction was to have the individual place one hand on the sternum and the other on the lower abdomen. Then, the individual was instructed to take a slow, deep breath in while imagining air filling their stomachs, causing the lower hand to rise gradually. In order for the lower hand to rise and fall while the upper hand remains largely motionless, breathing should be directed into the abdomen. The subject should visualise their entire body as a canister that is gradually filling with air, with the abdomen gradually expanding as the ribs broaden. At the same time, the subject focus on the area between the Ischium relaxing and widening to allow the pelvic floor muscles to lengthen out and let go.

Data Analysis:

The collected data were tabulated and analysed using both descriptive and inferential statistics. All the parameters were assessed using statistical package for social science (SPSS) version 24. Paired t-test was adopted to find the statistical difference within the groups and Independent t-test (Student t-Test) was adopted to find statistical difference between the groups.

Table 1: Comparison of Visual Analog Scale Score Between Group – A and Group - B in Pre and Post Test

Vas	Group – a		Group - b		T - Test	Df	Signif icance
Vas	Mean	S.D	Mean	S.D	T - Test	Df	Signif icance
Pre test	6.10	1.28	6.40	1.26	-0.526	18	0.605^*
Post test	3.30	1.41	5.10	1.28	-2.97	18	0.008**

Graph – I Comparison of Visual Analog Scale Score Between GROUP – A And Group - B in Pre and Post Test

Table 2: Comparison of Short form Survey- 36 Between Group – A and Group - B IN Pre and Post Test

SF-36	Group - A		Group - B		t - TEST
SF-36	Mean	S.D	Mean	S.D	t - TEST	Df	Significance
Pre test	436.30	119.46	441.00	77.46	-0.104	18	0.918^*
Post test	681.90	48.09	604.20	34.33	4.15	18	0.002**

Graph – II Comparison of Short form Survey- 36 Between Group – A and Group - B in Pre and Post Test

Table 3: Comparison Of PPI Questionnaire Score Between Group – A and Group - B in Pre and Post Test

PPIQ	Group - A		Group - B		t - Test	df	Significance
PPIQ	Mean	S.D	Mean	S.D	t - Test	df	Significance
Pre test	49.00	13.47	48.30	10.83	0.128	18	0.900^*
Post test	20.20	7.72	30.80	9.80	-2.68	18	0.016**

Graph – Iii Comparison of Ppi Questionnaire Score Between Group – A And Group - B in Pre and Post Test

Table – 4 Comparison of Visual Analog Scale Score Within Group – A and Group – B Between Pre And Post Test Values

VAS	Pre Test		Post Test		t - Test	Significance
VAS	Mean	S.D	Mean	S.D	t - Test
Group- A	6.10	1.28	3.30	1.41	21.00	0.000^***
Group- B	6.40	1.26	5.10	1.28	3.88	0.000^***

Graph – IV Comparison of Visual Analog Scale Score Within Group – A and Group – B Between Pre and Post Test Value

Table – 5 Comparison of Short Form Survey- 36 Score Within Group – A And Group – B Between Pre And Post Test Values

SF-36	Pre Test		Post Test		t – Test	Significance
SF-36	Mean	S.D	Mean	S.D	t – Test
Group- A	436.30	119.46	681.90	48.09	-6.97	0.000^***
Group- B	441.00	77.46	604.20	34.33	-8.98	0.000^***

Graph – V Comparison of Short Form Survey- 36 Score Within Group – A and Group – B Between Pre and Post Test Values

Table 6- Comparison Of Ppi Questionnaire Score Within Group – A and Group – B Between Pre and Post Test Values

PPIQ	Pre Test		Post Test		t - Test	Significance
PPIQ	Mean	S.D	Mean	S.D	t - Test
Group- A	49.00	13.47	20.20	7.72	12.00	0.000^***
Group- B	48.30	10.83	30.80	9.80	7.83	0.000^***

Graph – VI Comparison of PPI Questionnaire Score Within Group – A And Group – B Between Pre and Post Test Values

RESULTS:

On comparing the pre and post values within experimental group, it shows statistically significant improvement on visual analogue scale score (P ≤ 0.05) andPPI questionnaire score (P ≤ 0.05) and also in pre and post-test values of experimental groups, it reveals significant difference on short form survey – 36 score (P ≤ 0.05).

DISCUSSION:

The aim of the study was to find the effectiveness of myofascial therapy and pelvic relaxation exercise combined with phonophoresis using ultrasound with Diclofenac gel in subjects with myofascial pelvic pain syndrome. Myofascial treatment primarily entails analytical and comprehensive techniques including massage, stretching, release of trigger points through acupressure and dry needling, eradication of fascial mobility restrictions, and in situations of scarring, craniosacral rhythm control¹³. Exercises for pelvic relaxation resulted in modest pain alleviation and increased function in the participants¹⁴. According to research by Anna Szumilewic et al. in 2019, women who participated in a structured exercise programme with high- and low-impact aerobics and pelvic floor exercises experienced an improvement in their pelvic floor's neuromuscular activity during some motor tasks ¹⁵. Direct myofascial release aims to forcefully extend the constricted fascia. By releasing sticky tissues and deep tissues, direct release can alter the underlying architecture¹⁶. The application of Diclofenac gel has been effective in the management of arthritis¹⁷. The use of diclofenac is also cost effective which is successfully used in the treatment of many conditions¹⁸. The use of Diclofenac gel was effective in the management of Periodontitis¹⁹. Diclofenac gel was also combined with Paracetamol, Diclofenac Sodium and Chlorzoxazone²⁰ in an estimation study. Thiocolchicoside and Diclofenac Sodium was studied in a combined form in many pain conditions²¹. Capsule form of Diclofenac was also studied for its effectiveness²². The effect of diclofenac was analysed when it is combined with pantoprazole²³. In one study, a combination of Tramadol hydrochloride and diclofenac was studied for its effectiveness²⁴. Diclofenac was combined with Eperisone Hydrochloride and its effect on pain was tested in one study where diclofenac was proven to be effective²⁵. The effect of delayed release Diclofenac in the form of disintegrating tablets are also used in some research²⁶.

Women with MPPS usually experience pain with vaginal penetration, also known as dyspareunia, which has a range of medical explanations. Pharmacotherapy, psychiatric counselling, and physical therapy were frequently included in treatment strategies. When comparing the post-test mean valves for the visual analogue scale and the short form survey (SF-36), Group A (681.90) showed a better improvement in overall health-related quality of life than Group B (604.20), while in the PPI Questionnaire, Group A (20.20) showed a better improvement on symptoms of pelvic pain compared to Group B. (30.80). This study had investigated the effect of using MFT and PRE in MPPS. Subjects treated with MFT had significantly better improvement inall the parameters than subjects treated with PRE. Hence MFT could be a better treatment option for those suffering from MPPS.

CONCLUSION:

This study concluded that both myofascial therapy and pelvic relaxation exercise were effective in reduction of myofascial pelvic pain syndrome when combined with phonophoresis using ultrasound with Diclofenac gel. On comparing both the groups, Group-A (Myofascial Therapy) had improved in visual analogue scale, short form survey - 36 score and pelvic pain impact questionnaire than the Group-B (Pelvic Relaxation Exercise) in subjects with myofascial pelvic pain syndrome.

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Received on 27.10.2022 Modified on 18.06.2023

Research J. Pharm. and Tech. 2024; 17(3):1083-1087.

DOI: 10.52711/0974-360X.2024.00169