Background & Aims

Musculoskeletal (MSK) dysfunction is highly prevalent in women with Chronic Pelvic Pain (CPP)1-3, with prevalence ranging between 6.4 to 25.4%4. Clinical guidelines for CPP affirm that the MSK system can be both the primary or additional source of pain5. UK national guidance 5 on the assessment of Chronic Pain recommends assessment should include an attempt to identify factors contributing to the pain. Agreement on assessments in CPP is limited, impacting clinical decision making 4, 6-9.
In order to inform an evidence-based approach to assessment the measurement properties of a test such as validity, reliability, responsiveness, diagnostic accuracy, and utility need to established for the intended population. We conducted a systematic review to synthesis available evidence on the measurement properties of musculoskeletal tests for women with CPP.
Aims:
1. To determine
-which tests are used
-and the extent to which psychometric properties of tests have been assessed

Methods

The protocol was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42021285418) and reported considering the Preferred Reporting Items for Systematic Reviews (PRISMA)10.
The following databases were searched: CINAHL, MEDLINE, EMBASE, EMCARE, and AMED, with the final search completed on 31st July 2023.The Search Strategy centred on population (CPP) and assessment (musculoskeletal (MSK) tests). A data extraction tool was piloted, and data was extracted by 2/3 reviewers. Studies were quality assessed using either COSMIN17 or the Quadas-2 (diagnostic studies)11.
Primarily a narrative synthesis was conducted. Tests were grouped into the following categories according to purpose of test/s.
Data synthesis was according to the measurement properties reported, Synthesis provided summery statistics of these outcomes ie ICC.
Heterogeneity was informally investigated based on contextual factors (study design, population and setting).

Results

The search returned 9022 articles. Following removal of duplicates, 4480 titles and abstracts were screened, and 231 full text articles assessed for eligibility. A total of 49 articles met the inclusion criteria. See full details in the PRIMSA flow diagram.
A total of 64 different musculoskeletal tests were reported. The most frequently reported measurement property across all tests was validity (n=66). Utility was only reported in 3 studies.
eg:
Pelvic floor muscle function assessed using ultrasound (perineal and abdominal) was reported in 1 high21 and 2 moderate quality studies22-23. Transabdominal ultrasound was found to have high construct validity (when comparing ultrasound measurements in patients with low back pain compared with controls p=0.04) as well as demonstrating reliability (ICC=0.87)21. Similarly perineal ultrasound was found to be valid in women with dyspareunia (significant correlation in women with dyspareunia compared with controls in AP diameter measurement)

Conclusions

This review is able to recommend specific musculoskeletal tests for the use in the assessment of women with Chronic Pelvic Pain.
Further research should focus on understanding the utility and in some cases responsiveness of these tests. In the meantime, clinical consideration should be given to any tests that are intimate or pain provoking by nature.
The review is able to inform current clinical practice on the best evidence based approach to a systematic assessment of the pelvic musculoskeletal system. Future clinical guidelines should consider the findings of this review.

References

1. King PM, Myers CA, Ling FW et al. Musculoskeletal factors in chronic pelvic pain. J Psychosom Obstet Gynaecol. 1991; 12: 87-98. https://doi.org/10.1080/0167482X.1991.11742723
2. Montenegro ML, Vasconcelos EC, Candido Dos Reis FJ. Physical therapy in the management of women with chronic pelvic pain. Int J Clin Pract. 2008; 62: 263-269. DOI: 10.1111/j.1742-1241.2007.01530.x
3. Tu FF, Holt J, Gonzales J. Physical therapy evaluation of patients with chronic pelvic pain: a controlled study. Am J Obstet Gynecol. 2008; 198: 272.e1-7. doi:10.1016/j.ajog.2007.09.002
4. Ayorinde A, Macfarlane GJ, Saraswat L, Bhattacharya S. Chronic pelvic pain in women: an epidemiological perspective. Women’s Health. 2015; 11 (6): 851-864. DOI: 10.2217/whe.15.30
5. National Institute for Health and Care Excellence. Chronic Pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NICE guideline [NG193], 2021. https://www.nice.org.uk/guidance/ng193; Accessed 02.10.2023.
6. The European Society of Human Reproduction and Embryology: Endometriosis Guidelines, 2022. https://www.eshre.eu/Guideline/Endometriosis; Accessed 02.10.2023.
7. European Association of Urology Guidelines on Chronic Pelvic Pain, 2022. https://uroweb.org/guidelines/chronic-pelvic-pain; Accessed 02.10.2023.
8. Mandal D, Nunns D, Byrne M. British Society for the Study of Vulval Disease (BSSVD) Guideline Group: Guidelines for the management of vulvodynia. Br J Dermatol. 2010; 162 (6): 1180-1185. DOI 10.1111/j.1365-2133.2010.09684.x
9. Clemens JQ, Erickson DR, Varela NP, Lai HH. Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2022; 208(1):34-42 https://www.auanet.org/guidelines-and-quality/guidelines/diagnosis-and-treatment-interstitial-of-cystitis/bladder-pain-syndrome-(2022)
10. Page MJ, McKenzie JE, Bossuyt PM. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Br Med J. 2021; 372: n71. doi: https://doi.org/10.1136/bmj.n71
11. Whiting PF, Rutjes AWS, Westwood ME. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Annals of International Medicine. 2011; 18; (155): 529-36, 2011. doi: 10.7326/0003-4819-155-8-201110180-00009
12.

Presenting Author

Katie Gore

Poster Authors

Katie Gore

BSc(Hons)

Oxford University Hospitals NHS Trust

Lead Author

Topics

  • Specific Pain Conditions/Pain in Specific Populations: Abdominal and Pelvic Pain