Healthcare | Free Full-Text | Sexual Disability in Low Back Pain: Diagnostic and Therapeutic Framework for Physical Therapists
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3.4.1. “Standard Physical Therapy” Pathway
This pathway concerns the management of LBP-related sexual disability in the absence of relevant psychosocial or pathological issues. Therefore, this category includes symptomatic conditions linked to sexual activity without any presence of yellow or red flags and without any relevant influence by the relationship with one’s partner.
The Patient Reported Outcome Measures (PROMs) suggested to identify this condition and measure clinical outcomes are the ODI [55] or ALBPS [56] for disability and the Pain Self-Efficacy Questionnaire (PSEQ) [57] for predicting the patient adherence towards an active approach.
According to anamnestic collection and outcomes, different steps of rehabilitation are proposed: pain modulation, motor control training, stiffness or stabilization training, and functional training. Pacing activity and stay-active advice complete this program (see Figure 2).
Many patients report that pain prevents sexual intercourse. In this situation, pain should be reduced to enable sexual activity by using manual therapy [58,59], physical agents (e.g., transcutaneous electrical nerve stimulation) [60,61], and midrange low-load exercises. When pain is no longer inhibiting sexual activity, a PT may proceed with other steps of the therapeutic algorithm; if a patient reports no avoidance of sex because of pain, this therapeutic section can be skipped [62].
A key element of the rehabilitation program is lumbar motor control [63]. According to the studies on motion capture during coitus, through-range motor control of pelvic anti-/retroversion should be trained in the most frequent positions of sexual intercourse (e.g., supine, quadruped, prone, kneeling, seated, and standing) to allow patients to control complete lumbar ROM and increase spinal perception. The PT may use specific positions according to the patient’s evaluation [64].
Lumbar or hip stiffness could interfere with sexual intercourse and provoke/worsen pain in any position. For lumbar stiffness on the sagittal plane, flexion/extension movements are suggested; the progression may be from midrange to end-range movements and from low load (e.g., supine, prone) to half load (e.g., seated position) and full load (e.g., standing position). For lumbar stiffness in other planes, a PT may propose single-plane movements (e.g., rotation, side bending, and lateral shift), or multiplane movements. A little amount of pain should be tolerated, and the patient is encouraged to explore progressively wider ROM.
For hip stiffness, the program addresses the movements more involved in sexual activity: flexion, abduction, and external rotation [37].
Other patients need to improve spinal stabilization on the sagittal plane and/or other planes (e.g., coronal, transverse). Stabilization training is more than core muscle strengthening, involving both coordination among core muscles and motor relearning of inhibited muscles. Stabilization training in this field is an evolution of motor control training and should be performed in different intercourse positions, with the specific goal being to improve the quality of sex life [65].
The final step of this program should be functional training, which can be divided in three categories based on anamnesis: #1 “position change” (for patients reporting pain during position changing), #2 “static endurance” (for patients reporting pain while maintaining a position), and #3 “dynamic stabilization” (for patients reporting pain during/after sexual intercourse).
“Position change” training focuses on the ability to assume different positions, as usual during sexual activity, and can be trained by specific sequences of different positions with the aim of achieving pain-free movements between different sequences. “Static endurance” training is the completion of stabilization training but is more specific and progressive with regard to time and difficulty of sustained positions, with the aim of increasing the ability to stay in a position for a long time. “Dynamic stabilization” training aims to reproduce in the clinical setting the movements of sexual intercourse. Using bands, a PT can increase the force needed to complete these movements both in concentric and eccentric phases.
Pacing activity in this field is the patient’s education on how to manage symptoms during and after sexual activity. Patients can modulate sexual activity in three ways: the intercourse position, the intercourse intensity, and the stimuli for pleasure.
Figure 3 and Figure 4 show male and female intercourse positions from different studies [34,35,37,66], divided in supine, side-lying, prone, kneeling, seated, and standing.
First, the PT can advise using the more comfortable position and teach all variations allowed; then, positions that are more difficult may be introduced, for a short time, and alternated with positions that are more comfortable. Another strategy could be using more difficult positions at the beginning of the sexual intercourse and then use pain-free positions. The PT can advise patients on how to manage the onset or worsening of symptoms due to positioning during coitus.
Finally, stay-active advice means not only maintaining the usual activities of daily living (ADLs) and usual physical activity level but also modifying some risk factors for poor sex life related to habits. A PT can suggest patients increase their level of activity, especially aerobic (e.g., walking, cycling, Nordic walking, running, or swimming) [66,67,68,69,70]; reduce tobacco, alcohol, or drug consumption; manage sleep deprivation; and manage body mass index (BMI) and/or metabolic syndrome [71,72].
Every step of this program is related to a specific issue that may be addressed or not by a PT depending on patients’ anamnesis, physical examination, and tests/questionnaires. The focus is a tailored treatment for each single patient, applied with the graded activity and graded exposure concepts, together with stay-active advice, to restore sexual function to the maximum possible level.
3.4.2. “PIPT” Pathway
This pathway refers to patients with some yellow flags (e.g., kinesiophobia, catastrophizing, fear-avoidance behaviors, and low pain self-efficacy) or concerns about the possible negative influence of sexual life on partnership in absence of evident relationship alterations.
The PROMs suggested for identifying this condition and measuring clinical outcomes are the ODI [55], the ALBPS [56], and the Optimal Screening for Prediction of Referral and Outcome Yellow Flags (OSPRO—YF) [73] as multidimensional tools and the FABQ [27], the PCS [28], the PSEQ [57], and the Tampa Scale of Kinesiophobia (TSK) [74] as unidimensional tools.
PIPT represents the attention and attitude of the PT in exploring and treating the psychosocial aspects of patients complaining of LBP, taking care of sexual disability while improving symptoms and functional limitations. The therapeutic program is similar to the “Standard Physical Therapy” one, with more emphasis on the psychosocial aspects of rehabilitation and less on the mechanical ones.
Managing this situation, it is suggested to proceed with the four steps described in the “Standard Physical Therapy” picture (pain modulation, motor control training, stiffness or stabilization training, and functional training) together with pacing activity and stay-active advice, but the treatment should be oriented towards a specific psychological approach, like pain neuroscience education (PNE) or cognitive behavioral therapy (CBT).
PNE aims to shift from the concept of pain as a portrayal of harm to the concept of pain as an alarm system for tissue protection [75]. There is some growing evidence that it could be combined with usual care in individuals with LBP to reach better outcomes [76,77]. Patients need to know about their pain that pain does not mean hurt; pain experience is multifactorial; and pain overprotective systems can be retrained [78]. For this reason, PNE should be introduced for patients presenting yellow flags.
CBT is one of the nonpharmacological therapies of choice for chronic conditions, with proven effectiveness in the management of individuals complained of LBP [79,80]. It is a psychological approach focused on removing positive reinforcement of pain behaviors and promoting problem-solving behaviors, with an additional focus on changing unhelpful cognitions [81]. This kind of therapy or similar approaches may be useful in the management of sexual disability with psychosocial components.
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