Review article
Etiological, diagnostic and therapeutic consideration of the myofascial component in chronic pelvic pain
Consideración etiológica, diagnóstica y terapéutica del componente miofascial en el dolor pélvico crónico
E. Díaz-Mohedo
, F.J. Barón-López, C. Pineda-Galán
Corresponding author
Departamento de Fisioterapia, Universidad de Málaga, Málaga, Spain
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Díaz-Mohedo, F.J. Barón-López, C. Pineda-Galán" "autores" => array:3 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Díaz-Mohedo" "email" => array:1 [ 0 => "estherdiaz@uma.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "F.J." "apellidos" => "Barón-López" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Pineda-Galán" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Departamento de Fisioterapia, Universidad de Málaga, Málaga, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Consideración etiológica, diagnóstica y terapéutica del componente miofascial en el dolor pélvico crónico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1635 "Ancho" => 1670 "Tamanyo" => 176419 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Results of the systematic search strategy in PubMed and The Cochrane Library (2000–2009).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic pelvic pain (CPP) is that located at the level of the lower abdomen, pelvis, or intrapelvic structures that persists for at least 6 months. It occurs either continuously or intermittently, without being associated with a menstrual cyclical process or sexual intercourse.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Several studies agree about the high prevalence of the syndrome,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> providing figures around 12% of the U.S. general population<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and about 14.7% of American women between 18 and 50 years old,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> 21.5% in Australian women,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> 24–25.5% of females in New Zealand,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and 2–16% of the world population,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> with a lifetime incidence of 33%.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Epidemiologically, there is a higher incidence in women,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> which is 1.6/1000 in the UK every month, with an average length of the painful symptoms of 15 months.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Only 10% consults the gynecologist,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a> about 8% constitutes reason for consulting a urologist, and 1% for primary care physicians in the U.S.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> 25% of the cases are not diagnosed until 3–4 years after their first consultation. Curiously, in one third of women, the symptoms persist after two years; and of those, only 40% are referred to the specialist.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The impact on quality of life has been analyzed by several authors, estimating that 25% of women with CPP misses one and a half day of work per month, 58% has their normal activity restricted,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> 52.7% determines their social, family, and sexual activity, and up to 1% seeks psychological counseling.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> This condition affects approximately 10–16% of males, most often between 36 and 50 years of age, showing no apparent racial bias in either sex.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The economic impact of the disease is considerable, assuming investments that numerous specialists must cover and their corresponding diagnostic tests, around 158 million pounds in the UK and 881 million dollars in the U.S.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The consideration of the therapeutic approach of the myofascial component in the chain of treatments carried out by the specialists in charge of restoring the perineal function and alleviate pain is scarce, although this is considered an important component involved in these pathologies.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> This work attempts to justify the myofascial component as a protagonist in the etiology and clinical manifestation of the CPP and the genitourinary tract pathologies to which these symptoms are associated.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We performed a systematic review of PubMed and The Cochrane Library (2000–2009), after verification of keywords with Biomedical Thesaurus (<span class="elsevierStyleItalic">chronic pelvic pain</span>, <span class="elsevierStyleItalic">myofascial pain syndrome</span>, <span class="elsevierStyleItalic">physical therapy modalities</span>, <span class="elsevierStyleItalic">trigger points</span>), and we proceeded to the construction and development of the thematic tree that defines the search strategy, starting to make those combinations of key terms that bring us closer to the research topic.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The selection criteria used in this review include previous reviews, studies, and/or randomized controlled clinical trials with patients with CPP, as well as, although with less emphasis, retrospective investigations and opinions of experts on the subject in English that investigate on the etiology, diagnosis, and myofascial approach in CPP during the period between 2000 and 2009 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Synthesis of evidence</span><p id="par0035" class="elsevierStylePara elsevierViewall">Wesselmann and Czakanski,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> suggest that some of the factors that may be contributing to high rates of failure in the approach of CPP may be the lack of contemplation and differential diagnosis of visceral assessment and other systems, within which musculoskeletal and postural support are included. Potts and O’Dougherty,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> report the emergence of a new myofascial and muscular factor as an integral part of the etiological section explaining the CPP.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The importance of differentiating between a visceral referred pain and the myofascial pain and the trigger points (TP) that a visceral dysfunction can cause is extensively developed in the review by Doggweiler and Wiygul, who specify the triggering mechanisms in the formation of TP in the pelvic floor of patients with genitourinary dysfunction, and take that factor into consideration as etiologic, recommending infiltrations, stretchings, and manual treatment of such points as effective techniques in resolutive pain management.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">With the aim of providing a common consensus in the existing guidelines based on written evidence on diagnosis and therapeutic approaches of CPP, Jarrell et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> suggest a number of recommendations among which we find those that refer to the need to increase the knowledge about the involvement of the myofascial component in the etiology of the syndrome, as well as the possibility of access by these patients to multidisciplinary teams in which physiotherapy, through exercise and posture among other techniques, is a valid therapeutic option.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The variety of chronic symptoms surrounding bladder, urethra, prostate and colon pathologies may be caused, aggravated, or maintained by the existence of myofascial disorders and presence of TP in superficial and deep muscles of the perineum.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Similarly, the sacroiliac dysfunction is considered, with the consequent alteration of the myofascial component, as an important influence on the symptomatological development of these pathologies, considered a major cause of urogenital pain.</p><p id="par0055" class="elsevierStylePara elsevierViewall">There is evidence about the existence of an abdominal myofascial disorder in 15% of women with CPP.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,18</span></a> Thus, techniques aimed at both diagnosis and management of the component are proposed. Vincent insists on the importance of the development of the history and exploration, as these tools are the necessary key to identify the cause and the factors that perpetuate the symptoms, all in a multidisciplinary clinical setting.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Doggweilwe-Wiygul conducted a case study of 4 patients diagnosed with CPP, cystitis, and bladder irritative symptoms that he palpates and treats by infiltration and stretchings of the TP located in the piriformis, gluteal, and obturator internus muscles. The verification system of these points is based on the local spasm of the perineal muscles and pain referred during palpation.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Some sexual disorders such as premature ejaculation, decreased libido, or ejaculatory pain, are associated with CPP. In this sense, Anderson et al. treated the perineum TP of 146 men with CPP and rated the severity, frequency, and pain of the urinary and sexual symptoms according to the NIH-IC for one month. With a follow-up of 5 months, 70% of the subjects reported a decrease in pain of 9 points (35%) and 7 (26%) in the NIH-CPS (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). The sexual symptoms globally improved in 43% of the subjects (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001), but only 10% had a moderate improvement (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.96).<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Langfort performed a prospective study of 18 patients with urogynecologic pain (7 of them with interstitial cystitis) that had TP located in the levator ani, he assessed their sensitivity using a visual analogue scale, and he treated them with infiltration and post-puncture specific myofascial stretching.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> He achieved a success rate (pain reduction of 50%) of 72% immediately after the session, and absence of pain in 33%. Of the 7 women with cystitis, 71% had a decrease greater than 50% in the visual analogue scale.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Studying in depth the musculoskeletal system involvement in the etiology of CPP, Tu et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> conducted a prospective cross-sectional study in which they explored 20 patients with CPP and 19 healthy subjects. The major findings detected were asymmetrical iliac crests (61 vs. 25%), dysmetria at the level of the pubic symphysis (50 vs. 10%), and positive in the posterior sacroiliac provocation test (37 vs. 5%). These differences were statistically significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) in all cases. The patients equally showed more abdominal tension and had a mean perineal tension higher than the control cases, and less control over pelvic floor muscles (maintaining contraction for 10<span class="elsevierStyleHsp" style=""></span>s and relaxation). The high rate of muscle findings makes it necessary to consider the approach of this component specifically.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Other studies assessed postural changes, walking, mobility, sitting posture, and breathing and movement patterns (Mensendieck test) in patients with CPP.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Women with CPP obtained significantly lower punctuations than the control group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.01), highlighting an important difference in the walking (2.70<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.11 vs. control 5.60<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.09) and breathing patterns (patients 2.88<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.14 vs. control 5.63<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.10). Good discriminatory validity of the test and joint and/or first or second order muscle involvement accompanying the CPP are shown. Efficacy, measured in pain scores, of Mensendieck somatocognitive therapy compared to standard gynecological treatment in a randomized controlled study in 40 women affected by CPP has been proven.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> The best scores were for the experimental group, remaining after 90 days of receiving the treatment, and even a year after inclusion in the study.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Fenton et al. conducted a pilot study with 56 patients diagnosed with CPP in whom the pressure pain threshold (PPT) was rated in 14 TP located in the anterior abdominal wall, before and after randomly receiving one of the treatment options (infiltration in the TP or standard drug treatment).<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> They found weak correlation between PPT and other systems of measurement of pain (visual analogue scale). The PPT scores improved in 75% of those receiving infiltration, compared with 60% of those receiving drug treatment.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Another experimental multicenter randomized study, carried out for 6 months on 47 patients (23 men and 24 women), compared the effects of myofascial induction techniques with global massage techniques in patients with pelvic pain syndrome, measuring the pain and severity of the urinary symptoms (IC for women and NIH-CPSI for men), the quality of life (SF-12), and sexual health (FSFI).<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> The overall response rate in the myofascial induction group was significantly better (57%) than that obtained in the group undergoing general massage techniques (21%).</p><p id="par0095" class="elsevierStylePara elsevierViewall">In a cohort study in men with CPP, a relation was established between existing TP in the perineal area (7 points) and the areas of referred pain during palpation with the painful areas initially referenced by the patient. The referred pain occurred at least 50% of the times in 5 of the 7 TP palpated, and two of them referred pain in more than one anatomic site.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> The most frequent sites of irradiation were the penis (90.3%), the perineum (77.8%), and the rectum (70.8%). The puborectal, pubocoxigeo, and rectus abdominis TP reproduced penile pain more than 75% of the times. Palpation of the external oblique did so toward the suprapubic area, testicles and groin at least in 80% of the patients.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Taking the relation established by the authors between the myofascial system and its contribution to the development of the genitourinary symptoms into account, it seems that myofascial dysfunctions (perineal hypertonia and/or presence of TP) not only act as a trigger for the symptoms, but also contribute to the development of the visceral neurogenic-inflammatory process and can become a source of organ dysfunction.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> This myofascial involvement in pelvic pain has received several names, such as levator ani syndrome, perineal tension myalgia syndrome, and chronic pelvic pain syndrome. Such arbitrariness and confusion in the denomination of the same symptoms reflect the need for a consensus on diagnostic protocols that points to the triggers of the syndrome and guides toward an effective therapeutic approach.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In spite of the relation that some studies suggest between genitourinary disorders and sacroiliac dysfunction, none of them explains the biomechanic and/or myofascial involvement that such alteration may have. On the other hand, the electromyographic relation between coccygeal muscle hypertonia and lumbar iliocostalis muscle would explain the association of urogynecologic pathologies with backalgia.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0110" class="elsevierStylePara elsevierViewall">There is scientific evidence confirming the involvement of the myofascial system in the CPP, and it must encourage the specialist responsible for carrying out the resolution of this syndrome to design an intervention protocol that includes physiotherapy (with myofascial treatment manual techniques) as an effective alternative in the multidisciplinary approach of the symptoms.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres100029" "titulo" => array:6 [ 0 => "Abstract" 1 => "Context" 2 => "Objective" 3 => "Acquiring of evidence" 4 => "Synthesis of evidence" 5 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec87193" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres100028" "titulo" => array:6 [ 0 => "Resumen" 1 => "Contexto" 2 => "Objetivo" 3 => "Adquisición de evidencia" 4 => "Síntesis de evidencia" 5 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec87194" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Synthesis of evidence" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-05-20" "fechaAceptado" => "2010-06-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec87193" "palabras" => array:5 [ 0 => "Chronic pelvic pain" 1 => "Myofascial pain syndrome" 2 => "Physiotherapy" 3 => "Pelvic floor" 4 => "Trigger points" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec87194" "palabras" => array:5 [ 0 => "Dolor pélvico crónico" 1 => "Síndrome de dolor miofascial" 2 => "Fisioterapia" 3 => "Suelo pélvico" 4 => "Puntos gatillo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Context</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chronic pelvic pain is localized in the lower abdomen or pelvis and persists for at least 6 months. It may be continuous or intermittent, without association to a cyclic menstrual condition or to maintaining sexual relationships.</p> <span class="elsevierStyleSectionTitle">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To justify the important role played by the myofascial component in the etiology and clinical manifestation of chronic pelvic pain and encourage the consideration of a therapeutic approach to such component in the intervention protocols.</p> <span class="elsevierStyleSectionTitle">Acquiring of evidence</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A systematic review was made in PubMed and Cochrane Library (2000–2009) that included previous reviews, randomized controlled clinical studies, cohort studies and case studies with patients suffering chronic pelvic pain.</p> <span class="elsevierStyleSectionTitle">Synthesis of evidence</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Chronic pelvic pain and the different conditions associated to it occur with myofascial alterations that may be responsible for the perpetuation of the body symptoms and lack of evolutive resolution of the condition when such component is not approached in a specific way.</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">This is a clinical situation with elevated prevalence and incidence with significant impact in terms of quality of life and financial cost.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Contexto</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El dolor pélvico crónico se localiza al nivel del abdomen inferior o pelvis y persiste durante al menos 6 meses. Puede presentarse de forma continua o intermitente, sin que se asocie a un proceso cíclico menstrual o al mantenimiento de relaciones sexuales.</p> <span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Justificar el protagonismo del componente miofascial en la etiología y manifestación clínica del dolor pélvico crónico y animar a considerar el abordaje terapéutico de dicho componente en los protocolos de intervención.</p> <span class="elsevierStyleSectionTitle">Adquisición de evidencia</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se realiza una revisión sistemática en PubMed y Cochrane Library (2000-2009) que incluye revisiones previas, estudios clínicos aleatorizados controlados, estudio de cohortes y estudio de casos con pacientes afectos de dolor pélvico crónico.</p> <span class="elsevierStyleSectionTitle">Síntesis de evidencia</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El dolor pélvico crónico y las diversas patologías asociadas cursan con alteraciones miofasciales, que pueden ser responsables de la perpetuación de los síntomas orgánicos y de la falta de resolución evolutiva del proceso cuando dicho componente no se aborda específicamente.</p> <span class="elsevierStyleSectionTitle">Conclusión</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se trata de un cuadro clínico de elevada prevalencia e incidencia que tiene importante impacto en términos de calidad de vida y de gasto económico.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Díaz-Mohedo E, et al. Consideración etiológica, diagnóstica y terapéutica del componente miofascial en el dolor pélvico crónico. Actas Urol Esp. 2011;35:610–14.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1635 "Ancho" => 1670 "Tamanyo" => 176419 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Results of the systematic search strategy in PubMed and The Cochrane Library (2000–2009).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Physical therapy in the management of women with chronic pelvic pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.L.L.S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 0 | 8 | 8 |
| 2024 September | 0 | 5 | 5 |
| 2024 August | 0 | 12 | 12 |
| 2024 July | 0 | 6 | 6 |
| 2024 June | 0 | 5 | 5 |
| 2024 May | 0 | 7 | 7 |
| 2024 April | 0 | 6 | 6 |
| 2024 March | 0 | 6 | 6 |
| 2024 February | 0 | 5 | 5 |
| 2024 January | 0 | 3 | 3 |
| 2023 December | 0 | 2 | 2 |
| 2023 November | 0 | 12 | 12 |
| 2023 October | 0 | 19 | 19 |
| 2023 September | 0 | 18 | 18 |
| 2023 August | 0 | 10 | 10 |
| 2023 July | 0 | 37 | 37 |
| 2023 June | 0 | 3 | 3 |
| 2023 May | 0 | 2 | 2 |
| 2023 April | 0 | 3 | 3 |
| 2023 March | 3 | 8 | 11 |
| 2023 February | 0 | 9 | 9 |
| 2023 January | 0 | 6 | 6 |
| 2022 December | 0 | 5 | 5 |
| 2022 November | 0 | 14 | 14 |
| 2022 October | 0 | 9 | 9 |
| 2022 September | 0 | 2 | 2 |
| 2022 August | 0 | 6 | 6 |
| 2022 July | 0 | 4 | 4 |
| 2022 June | 0 | 7 | 7 |
| 2022 May | 0 | 11 | 11 |
| 2022 April | 0 | 5 | 5 |
| 2022 March | 0 | 11 | 11 |
| 2022 February | 0 | 10 | 10 |
| 2022 January | 0 | 3 | 3 |
| 2021 December | 0 | 7 | 7 |
| 2021 November | 0 | 4 | 4 |
| 2021 October | 0 | 1 | 1 |
| 2021 September | 0 | 5 | 5 |
| 2021 August | 0 | 1 | 1 |
| 2021 July | 0 | 1 | 1 |
| 2021 June | 0 | 3 | 3 |
| 2021 May | 0 | 1 | 1 |
| 2021 April | 0 | 36 | 36 |
| 2021 March | 0 | 27 | 27 |
| 2021 February | 0 | 6 | 6 |
| 2021 January | 0 | 3 | 3 |
| 2020 December | 0 | 4 | 4 |
| 2020 November | 0 | 5 | 5 |
| 2020 October | 0 | 1 | 1 |
| 2020 September | 0 | 4 | 4 |
| 2020 August | 0 | 8 | 8 |
| 2020 July | 0 | 3 | 3 |
| 2020 June | 0 | 6 | 6 |
| 2020 May | 0 | 6 | 6 |
| 2020 April | 0 | 2 | 2 |
| 2020 March | 0 | 4 | 4 |
| 2020 February | 0 | 2 | 2 |
| 2020 January | 0 | 5 | 5 |
| 2019 December | 0 | 9 | 9 |
| 2019 November | 0 | 8 | 8 |
| 2019 October | 0 | 5 | 5 |
| 2019 September | 0 | 1 | 1 |
| 2019 August | 0 | 3 | 3 |
| 2019 July | 0 | 7 | 7 |
| 2019 June | 0 | 13 | 13 |
| 2019 May | 0 | 49 | 49 |
| 2019 April | 0 | 18 | 18 |
| 2019 March | 0 | 2 | 2 |
| 2019 February | 0 | 3 | 3 |
| 2019 January | 0 | 1 | 1 |
| 2018 December | 0 | 2 | 2 |
| 2018 November | 0 | 3 | 3 |
| 2018 February | 15 | 1 | 16 |
| 2018 January | 22 | 2 | 24 |
| 2017 December | 15 | 1 | 16 |
| 2017 November | 14 | 1 | 15 |
| 2017 October | 21 | 3 | 24 |
| 2017 September | 22 | 4 | 26 |
| 2017 August | 13 | 2 | 15 |
| 2017 July | 14 | 5 | 19 |
| 2017 June | 47 | 24 | 71 |
| 2017 May | 19 | 2 | 21 |
| 2017 April | 17 | 1 | 18 |
| 2017 March | 19 | 2 | 21 |
| 2017 February | 17 | 3 | 20 |
| 2017 January | 17 | 2 | 19 |
| 2016 December | 30 | 4 | 34 |
| 2016 November | 31 | 5 | 36 |
| 2016 October | 60 | 5 | 65 |
| 2016 September | 20 | 10 | 30 |
| 2016 August | 28 | 5 | 33 |
| 2016 July | 19 | 4 | 23 |
| 2016 June | 15 | 5 | 20 |
| 2016 May | 18 | 13 | 31 |
| 2016 April | 25 | 11 | 36 |
| 2016 March | 26 | 16 | 42 |
| 2016 February | 29 | 28 | 57 |
| 2016 January | 33 | 21 | 54 |
| 2015 December | 20 | 13 | 33 |
| 2015 November | 17 | 10 | 27 |
| 2015 October | 11 | 5 | 16 |
| 2015 September | 16 | 3 | 19 |
| 2015 August | 38 | 6 | 44 |
| 2015 July | 18 | 5 | 23 |
| 2015 June | 8 | 2 | 10 |
| 2015 May | 19 | 3 | 22 |
| 2015 April | 36 | 8 | 44 |
| 2015 March | 17 | 4 | 21 |
| 2015 February | 24 | 2 | 26 |
| 2015 January | 40 | 6 | 46 |
| 2014 December | 37 | 11 | 48 |
| 2014 November | 33 | 3 | 36 |
| 2014 October | 64 | 16 | 80 |
| 2014 September | 52 | 11 | 63 |
| 2014 August | 63 | 16 | 79 |
| 2014 July | 29 | 13 | 42 |
| 2014 June | 20 | 12 | 32 |
| 2014 May | 18 | 9 | 27 |
| 2014 April | 15 | 11 | 26 |
| 2014 March | 29 | 9 | 38 |
| 2014 February | 21 | 4 | 25 |
| 2014 January | 28 | 9 | 37 |
| 2013 December | 29 | 6 | 35 |
| 2013 November | 29 | 12 | 41 |
| 2013 October | 14 | 9 | 23 |
| 2013 September | 9 | 5 | 14 |
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