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Redondo Beach, CA May 20, 2013. Vickie Jenni Gabelsberg DPT, MSc, MTC, WCS, BCIA-PMDB Owner/Director Women’s Advantage, Inc. Torrance, CA.

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Presentation on theme: "Redondo Beach, CA May 20, 2013. Vickie Jenni Gabelsberg DPT, MSc, MTC, WCS, BCIA-PMDB Owner/Director Women’s Advantage, Inc. Torrance, CA."— Presentation transcript:

1 Redondo Beach, CA May 20, 2013

2 Vickie

3 Jenni Gabelsberg DPT, MSc, MTC, WCS, BCIA-PMDB Owner/Director Women’s Advantage, Inc. Torrance, CA

4  History of hysterectomy and bladder sling with mesh 4 years prior  History of mild urinary frequency and nocturia 2x/night  4 months before eval, self treated a yeast infection with Monistat

5  At eval: pt could not sit or walk prolonged, wear tight clothing/jeans, or tolerate intercourse  Urethral pressure with sitting  Severe pain at vestibule, worsened by touch, and worst at night  Pain rated as 10/10 without neurontin and 3/10 with meds (300 mg TID)

6  Red irritated vestibule at 4 and 8 o’clock positions, mild tenderness with Q Tip test  Thinning and pale labia  PFM MMT 2/5 (poor) with a 2-3 second hold

7 Hypertonus and pain found with palpation of:  Bulbocavernosus, ischiocavernosus, STP (severe)  Urogenital diaphragm ms (mild)  Pubococcygeus, iliococcygeus, coccygeus and OI (moderate)

8  Tightness found in bilateral hamstrings, adductors, iliopsoas, piriformis and gluteal muscles (with poor connective tissue mobility)  Weak abdominal, lumbar and pelvic girdle stabilizers

9  Intravaginal Manual Therapy  LE and trunk stretching  Biofeedback evaluation – modified Glazers protocol given for HEP  Cold laser

10  Connective Tissue Mobilization: Adductors Anterior thigh and inguinal region Labia Abdomen Posterior thigh Gluteals

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14 Piriformis Obturator Internus

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18 Also known as low level light therapy, NON thermal Effects:  Increase ATP at cellular level  Stimulation of mitochondria, cellular enzymes, macrophage activation, collagen synthesis, increase in granulation tissue, increased serotonin and endorphin with decreased c fiber (pain) activity.  Uses: inflammatory conditions, wound care and tissue repair, pain control

19  30-40% improvement in vulvar pain  Able to sit minutes depending on the surface  Still unable to wear tight clothing  Decreased external vestibular pain by 95%  Able to tolerate orgasm but pain/”tingling” continued for 24 hours after  Zero penetration

20  Zero pain at vestibule with touch  Brief shooting pains at anterior vulva  Tingling nerve pain remains 80% of the time, worsens with sitting  Can put on jeans and zip up, but has not tried sitting or wearing out  Still wearing sweat pants all the time  min sitting tolerance – better on soft surfaces  Describes feelings of pelvic “congestion” and “heaviness”

21  Began neural glides of the pudendal nerve  Added sacrotuberous ligament release

22 It will cross under the piriformis, leaves the pelvis through greater sciatic foramen, then back through lesser sciatic foramen, over the sacrospinous ligament, under the sacrotuberous ligament

23 1. Dorsal nerve of the clitoris or penis 2. The perineal branch  Urethral sphincter  Perineal muscles and sensation 3. The inferior rectal or hemorrhoid nerve  External anal sphincter (EAS)  Perianal sensation

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25  Obturator Internus  Sacrotuberous Ligament  Sacrospinous Ligament

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27  75% overall improvement, pain rated 4-5/10  Now able to wear jeans 5-6 hours, able to wear underwear  Able to sit through dinner with her family  Able to sit on a hard surface 5-10 minutes, soft surface for 2 hours  Able to have intercourse with no vulvar or vaginal pain during

28  80-85% improvement, pain rated 2-3/10  Sitting is still her most pain provoking activity  Now able to walk up and down hills, stairs and do pilates  Able to sit 3 hours at hairdresser  Meds – Estrace 3x/wk, Neurontin increased to 2400 mg/day

29  Thoracic and lumbar joint mobilizations  Heat and Interferential electrical stimulation to thoracic spine  Given a TENS unit to do EMS at home  Postural education/core training

30  90% improved  Sitting still limited by vulvar and buttock/posterior thigh pain  Able to walk 7 miles at beach with zero exacerbation in symptoms  External vulva healthy  Pain free standing tolerance  Able to wear jeans and underwear all day

31  Increased external manual therapy to levator ani ms, adductor attachment onto pubic rami, Obturator Internus ms, coccygeus  Focused internal MT to iliococcygeus, coccygeus and OI

32  April 11, 2013 had first caudal nerve block with significant improvement in nerve pain, zero radiating buttock pain, scheduled for weekly injections Pt treatments focus on:  External MT to levator ani, adductors  CTM to adductors

33  Intravaginal MT to urogenital diaphragm and levator ani ms  ART to proximal hamstrings  Hip mobilizations with neuromuscular re-ed, glut strengthening  Heat with IFC/EMS to gluteals and lumbosacral spine  Neural Glides to Pudendal nerve  Cold laser

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35  90% improved  Pain continues to “move around pelvis”  Most consistent pain is buttock pain with any prolonged sitting  Able to participate in family activities, camping, exercise


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