As a women’s health physical therapist specializing in pain and scar tissue, I frequently see patients in clinic with intense, often debilitating pain caused by endometriosis. These women have often tried every treatment made available to them: surgery to cut adhesions and remove endometrial growths, hormone treatments, and symptom control (usually in the form of strong pain killers, anti- nausea, anti-depressant, and anti-anxiety medications). Despite these interventions, some patients report continued or even worsening pain. In the worst cases, their quality of life has been disrupted to the point of suicidal thoughts.
Endometriosis and Adhesions
How does it get so bad? It has to do with the chronic inflammation that endometriosis causes wherever it resides in the body. Inflammation is a natural part of the body’s healing process. In normal healing inflammation is followed by the re-building processes to form new tissue, for example scars, that repairs the area. In chronic inflammation such as endometriosis, this scarring process continues, continuously build scars, or adhesions, that are not needed by the body. As these adhesions form they can limit normal mobility of organs and connective tissue, put pressure on pain sensitive structures, and disrupt the function of the tissues they restrict. Because endometriosis continues to remain in the body, these symptoms can get worse over time. If the endometriosis or adhesions are surgically removed, the surgery itself may cause new adhesions and scar tissue to form.
With the chronic pain and chronic inflammation caused by endometriosis, other issues may develop. The muscles of the pelvic floor may go into spasm or constantly be too tight. This can cause pain with intercourse, difficulty using tampons, or difficulty controlling bladder or bowel function. The nerves in the skin of the groin and genitalia may become over stimulated and confuse light touch with pain. Bladder issues, gastrointestinal symptoms, postural changes, even lower back and neck pain can occur as the body deals with the chronic inflammatory process and pain.
Physical Therapy for Endometriosis Adhesions
When I feel the abdomen and pelvis in my patients with endometriosis, the tissue texture and mobility of the organs is often very different from that of unaffected tissue. Sometimes this is throughout the pelvis, other times it is only in very focal locations. The restrictions are not always in the same location as the primary area of pain. Because everything in the body is connected through the fascia (another name for connective tissue), restriction in one area can pull into other more distant areas. Imagine a spider web: tension at one point in the web can pull across to multiple other points.
Using specialized manual therapy techniques these adhesions and fascial restrictions can be softened or released, so that the pressure they put on surrounding areas is relieved (research on this is aspect of treating endometriosis adhesions is ongoing by the Clear Passage physical therapy group[i]). If the endometriosis is active, it is always possible that new fascial restrictions will reform, due to the continued chronic healing process that is ongoing in the body. However by learning self-treatment techniques patients can often manage their own symptoms quite well.
Physical Therapy Treatment Possibilities
What might treatment by a women’s health physical therapist entail? Treatment of scar tissue and fascia typically involves applying pressure to restricted areas, over a prolonged period of time. This can sometimes be uncomfortable, and can even mimic the pain you feel from endometriosis. This is one reason that having a good rapport and open communication with your therapist is so important. Treatment of the pelvic floor typically involves internal vaginal work, and sometimes includes internal rectal treatment. This is almost like going to the gynecologist, in that the therapist will use gloved and lubricated fingers to evaluate and treat the pelvic floor muscles and other internal structures. As you can imagine not every physical therapist does this kind of work! It requires additional training beyond licensure and it is very important that your therapist has experience working patients with endometriosis specifically. The patient should always feel confident in the expertise of their therapist and comfortable during treatment. They will be draped for modesty, educated on the evaluation and treatment to occur, and asked for feedback as treatment progresses.
Does it Work?
Endometriosis can cause life-altering pain and dysfunction. Fortunately, I have seen remarkable results using physical therapy, both to treat the scarring and adhesions associated with endometriosis, as well as the constellation of other symptoms that may develop. Physical therapy techniques such as Barnes Myofascial Release (MFR) and the Wurn Technique™ can be used to treat fascial restrictions and adhesions. Techniques such as MFR, trigger point release, soft tissue mobilization, biofeedback, and others can be used to treat the pelvic floor. Very importantly, the physical therapist should be experienced in specifically treating patients with endometriosis.
The take-home message I would like to impart is this: have hope. Physical therapy is a powerful tool that can be used to help patients with endometriosis decrease pain, increase function, and improve their quality of life.
[i] Wurn, B., Wurn, L., Patterson, K., King, R., & Scharf, E. Decreasing dyspareunia and dysmenorrhea in women with endometriosis via a manual physical therapy: Results from two independent studies . Journal of Endometriosis, 3, 188-196.