More on pelvic floor tension

"Most patients undergo myriad tests and studies to uncover the source of their pain—but a targeted pelvic exam may be all that is necessary to identify a prevalent but commonly overlooked cause of pelvic pain. Levator myalgia, myofascial pelvic pain syndrome, and pelvic floor spasm are all terms that describe a condition that may affect as many as 78% of women who are given a diagnosis of chronic pelvic pain.¹ This syndrome may be represented by an array of symptoms, including pelvic pressure, dyspareunia, rectal discomfort, and irritative urinary symptoms such as spasms, frequency, and urgency. It is characterized by the presence of tight, band-like pelvic muscles that reproduce the patient’s pain when palpated.²

"Although the concept of a muscle spasm is not foreign, the location is unexpected. Patients and physicians alike may forget that there is a large complex of muscles that completely lines the pelvic girdle....Although a muscle spasm may be the cause of the patient’s pain, it’s important to realize that an underlying process may have triggered the original spasm. To provide effective treatment of pain, therefore, you must identify the fundamental cause, assuming that it is reversible, rather than focus exclusively on symptoms.


"Physical therapy of the pelvic floor—otherwise known as pelvic myofascial therapy—requires a therapist who is highly trained and specialized in this technique. It is more invasive than other forms of rehabilitative therapy because of the need to perform transvaginal maneuvers (FIGURE 1).

This pilot study by the Urological Pelvic Pain Collaborative Research Network evaluated the ability of patients to adhere to pelvic myofascial therapy, the response of their pain to therapy, and adverse events associated with manual therapy. It found that patients were willing to undergo the therapy, despite the invasive nature of the maneuvers, because it was significantly effective.

 

"Nevertheless, patients who suffer from chronic pelvic pain may take heart that there is a nonpharmaceutical alternative to manage their symptoms, although availability is likely limited in many areas. Given the nature of the physical therapy required for this particular location of myofascial pain, specialized training is necessary for therapists. Despite motivated patients and well-informed providers, it may be difficult to find specialized therapists within local vicinities. Referrals to centers where this type of therapy is offered may be necessary.

 

Weighing the nonpharmaceutical options for treatment of myofascial pelvic pain

Treatment	Pros	Cons
Physical therapy	Minimally invasive Moderate long-term success	Requires highly specialized therapist
Trigger-point injection	Minimally invasive Performed in clinic Immediate short-term success	Optimal injectable agent is unknown Botulinum toxin A lacks FDA approval for this indication Limited information on adverse events and long-term efficacy
Percutaneous tibial nerve stimulation	Minimally invasive Performed in clinic	Requires numerous office visits for treatment Lacks FDA approval for this indication Limited information on long-term efficacy
Sacral neuromodulation	Moderately invasive Permanent implant	Requires implantation in operating room Lacks FDA approval for this indication Limited information on long-term efficacy

 

 

 

See more at: http://www.obgmanagement.com/home/article/update-on-pelvic-floor-dysfunction/9f178df5dcf8707bc5a96f880f75deee.html

 

"A plethora of various terms/diagnoses encompass pelvic pain as a symptom, including but not limited to: chronic pelvic pain (CPP), vulvar pain, vulvodynia, vestibulitis/vestibulodynia (localized provoked vestibulodynia or unprovoked vestibulodynia), vaginismus, dyspareunia, interstitial cystitis (IC)/painful bladder syndrome (PBS), proctalgia fugax, levator ani syndrome, pelvic floor dysfunction, vulvodynia, vestibulitis/vestibulodynia dyspareunia, vaginismus, coccygodynia, levator ani syndrome, tension myaglia of the pelvic floor, shortened pelvic floor, and muscular incoordination of the pelvic floor muscles.¹

 

"Vulvodynia is associated with other pain conditions such as: fibromyalgia, irritable bowel syndrome, tempromandibular joint dysfunction, and interstitial cystitis/painful bladder syndrome. Pelvic floor over activity is found in 80-90% of these patients....³

 

"Interstitial cystitis (IC) or painful bladder syndrome (PBS) is defined as pelvic pain associated with urinary frequency, urgency, and irritable voiding.  It can be associated with vulvodynia, irritable bowel syndrome, endometriosis, fibromyalgia, and chronic fatigue syndrome.  It is estimated that 50-87% of patients with IC/PBS have pelvic floor muscle overactivity.³ The sensation of the need to void is associated with the pressure from the pelvic floor muscle over activity.  Pelvic floor physical therapy is more successful with this population compared to treatment directed at the bladder. ³

"Proctalgia fugax and levator ani syndrome are two anal region pain conditions that are associated with hypertonic pelvic floor musculature.  Proctalgia fugax is a sudden, severe, transient attack of pain in the rectum lasting less than five minutes.  Levator ani syndrome is defined as a near constant pain of a dull ache nature in the anal and rectal region.  Because of the presence of pelvic floor muscle over activity, the failure of the pelvic floor muscles to relax can lend to incomplete defecation and post defecatory pain inside the anus.³

 

^"Varying mechanisms can also contribute to the maintenance and evolution of CPP.  One hypothesis is: neuroplastic changes that occur in the posterior horn of the spinal cord, which can lead to neurologic inflammation and cross-sensitivity of the viscera and muscles, share innervation. Due to these aforementioned mechanisms, an overlap of symptoms including: dyspareunia, dysmenorrhea, gastrointestinal complaints, genitourinary complaints, and musculoskeletal complaints can occur with CPP.⁵ In particular, irritable bowel syndrome (IBS), fibromyalgia, and interstitial cystitis are common co-morbidities of patients with CPP. ² Furthermore, there is strong evidence that currently demonstrates the involvement of the musculoskeletal system in CPP.⁵ Over activity in the pelvic floor musculature is found in up to 80-90% of patients with vulvodynia.^{3, 6} Dysfunction of the musculoskeletal system can lead to the adoption of abnormal postures which contribute to increased tension, spasm, and adaptive muscle shortening that can exacerbate or perpetuate the pain.⁵ 

 

 

 

"...when treating this population, it is important to address the myofascial component of pain to be successful in treatment. ³ Physical therapists are treating a specific musculoskeletal dysfunction such as muscle spasm, myofascial restriction, muscle incoordination, and impaired activities of daily living in patients with vulvar pain. ²

 Indications for Treatment: ⁸

• Increased pain (including vaginal, rectal, suprapubic, vulvar region)
• Urinary urgency/frequency/incontinence
• Impaired muscle performance
• Impaired functional mobility
• Increased joint mobility
• Impaired boney alignment
• Impaired posture

Contraindications / Precautions for Treatment: ⁸

The following precautions/contraindications refer to the performance of an internal pelvic floor examination:

• Pregnancy (must receive written consent from patient’s obstetrician)
• Active pelvic infections of the vagina or bladder
• Active infectious lesions (i.e.: genital herpes)
• Current yeast infection
• Immediately post pelvic radiation treatment (within 6-8 weeks without physician approval)
• Immediate post pelvic surgery or postpartum (within 6-8 weeks without physician approval)
• Severe atrophic vaginitis
• Severe pelvic pain
• History of sexual abuse
• Lack of patient consent
• Pediatric patients
• Absence of previous pelvic exam
• Inadequate training on the part of the physical therapist

The following precautions/contraindications refer to patients who are currently pregnant: ⁹

• Deep heat modalities (ultrasound) and electrical stimulation
• Manual therapy techniques that may increase laxity
• Maintaining supine positions longer than three minutes after the fourth month of pregnancy

" Oral contraceptives have been recently linked as a possible contributor to the development of pelvic pain.¹⁴ A lifetime risk of 6.6 of developing localized provoked vestibulodynia when using oral contraceptives has been found.¹⁵ Topical medications are often used with vulvar pain.  Topical gabapentin has also been shown to reduce vulvar pain. Topical steroids are another class of medication that are used if the patient has an accompanying inflammatory skin condition, such as lichens sclerosis.¹⁶ Lidocaine applied topically to the vulva is a commonly used treatment strategy.  Local estrogen has also been used in cases where there is a specific lack of local estrogen, as in post-menopausal conditions and thyroid disorders.¹⁵  Tricyclic antidepressants are typically used as first line treatment for vulvar pain (amitriptyline, desipramine, and nortriptyline are commonly used and used at lower doses that would be used for depression).^15,16  Furthermore, anti-epileptic drugs including gabapentin or pregabalin have also been used to decrease pain, especially associated with unprovoked vulvodynia.¹⁵

 

"Examination:

Most pelvic floor exams include a detailed medical history, posture assessment, pelvic floor muscle exam, sensory, coordination, and neurological testing, pelvic girdle and associated structure exam, bowel and bladder function including voiding diaries, digital and surface electromyography, hip, sacroiliac, and spinal mobility, abdominal, and lower extremity strength testing.²

 

Observation/Visual Inspection:

• Gait- The patient may present with an abnormal or antalgic gait pattern.⁵ Decreased or increased pelvic mobility may be observed during gait by observing quantity of movement of the pelvis in both the sagittal and transverse planes.
• Function- Patients may have difficulty with prolonged sitting, standing, ambulation, activities of daily living, as well as bladder and bowel functioning and intercourse.
• Posture/Alignment: 

o   AROM of the spine, quadrant tests, passive segmental mobility may reveal specific facet joint dysfunction, facilitated segments, and motion restrictions.²

o   Head alignment, shoulder positioning and symmetry, scoliosis, as well as pelvis and lower extremities should be analyzed for postural deviations.⁵   

o   Muscle imbalances may occur in and around the pelvic girdle, hips, and trunk because of muscle pain and become chronic once established.

o   Typical pelvic pain posture has been found in 75% of women with CPP which includes: exaggerated lumbar lordosis, increased anterior pelvic tilt, increased thoracic kyphosis.¹⁷

o   Abnormal sitting postures may also be found such as increased weight distribution on the sacrum instead of ischial tuberosities.¹⁸ Patients may exhibit shifting and frequent changes of position while standing. Patients may favor weight bearing on one side, which may contribute to muscle imbalances between the gluteus medius and the tensor fascia lata.

o    Toileting and intercourse positions should also be reviewed.

• Pain: Pain location can be in the vagina, vulva, rectum, suprapubic region, or lower abdomen. Pain can also radiate into the back and hips. Pain reports associated with pelvic floor muscle (PFM) over activity are often vague and poorly localized and defined as aching, throbbing, pressure-like or heavy. Pain can be provoked as the day progresses or during activities specifically involving the pelvic floor such as walking, sitting, exercise, intercourse, urinating, and defecating.³

 

Examination/Palpation:

(Please refer to Hand Washing Protocol for details)

• External Trunk and Abdominal Palpation:

o   The clinician may start with an observation and examination of the pelvic bones and lower extremities to determine the presence of pelvic obliquities, innominate rotation or shear dysfunctions, and sacral positional or movement dysfunctions.^{2, 8} Please refer to the Pelvic Girdle Pain Standard of Care and the Special Tests Task Force document of preferred tests to examine this area.

§  Testing may include:  sacroiliac joint compression/distraction, FABER, Gaenslen’s test, standing forward bend, spring rests, and stork test (see Special Test Task Force SI Tests for details)

o   A lower quarter screening examination including reflex testing and dermatomal testing for sensation impairment is conducted, assessing for possible adverse neural tension of the lower quarter nerves.  This would be revealed with specific positional testing to help determine if the pain in the pelvis is resulting from pudendal, obturator, sciatic, ilioinguinal, or genitofemoral nerve compression, adherence, or restriction.²

o   External palpation of the abdominal wall, including any scarring or deformities and assessment of any abdominal trigger points or adhesions should be made. ² Palpation of the bilateral iliacus, psoas, abdominal obliques, rectus abdominis, and quadratus lumborum muscles should also be performed, as these muscles can be commonly involved with those with pelvic pain. ⁷ Carnett’s test can be conducted to differentially diagnose between visceral and musculoskeletal causes of pain in this region.^4,5  Diastasis recti testing should also be conducted to determine any separation and possible reduced stability of the rectus abdominis muscles.⁴

o   Evaluative findings in this area may include: thoracolumbar and sacroiliac joint dysfunction, pubic bone malalignment, coccyx dysfunction, hip impairments, lower quarter flexibility and strength impairments, pelvic ligamentous tautness or laxity, and dysfunctional muscle firing or movement patterns.²

• ROM: Assessment of the range of motion of the lumbar spine, hips, and sacroiliac joints, and coccyx is also conducted. 
• Strength:  Manual muscle testing of the abdominal region and lower extremities is conducted. The pelvic floor muscles are tested for strength as well, using the Modified Oxford Laycock scale for assessment described in a later section.²

Rehabilitative ultrasound imaging (RUSI) can also be used to assess the timing and accuracy of the pelvic floor muscles as well as the transverse abdominis contraction to facilitate its correct timing during functional and strengthening activities (described later).² 

• Sensation: Lower extremity and perineal sensation should be assessed for any alterations or deficits.

• External Pelvic Floor Palpation:

o   A physical therapy exam of the pelvic floor starts with observation of the external perineum to assess for swelling, asymmetry, color, and skin changes.  If dermatoses are noted, the patient may be referred back to MD for further evaluation of such conditions.  Also, external examination of the vulva, vestibule, urethra, and external pelvic floor (pelvic clock) should be assessed for injuries, irritation, adhesions, scarring, or trigger points. 

o   External observation of a pelvic floor muscle contraction and relaxation is observed to see recruitment, coordination, and symmetry of the pelvic floor and anal sphincter activity. Neurological exam including reflex testing of the anal wink and bulbocavernosus reflex can occur, along with external palpation of the superficial PFM for pain and trigger points, shortening and spasm.²

o   The cotton swab test can be conducted.  This test helps to determine the patient’s irritability and tolerance to pressure or contact on the vestibular tissue and is considered to be a hallmark of localized provoked vestibulodynia. A cotton swab moistened with water is applied lightly, deflecting the skin 1 mm, around the areas of the vestibule at the following locations: 12:00, 12-3:00 quadrant, 3-6:00 quadrant, 6-9:00 quadrant, and 9-12:00 quadrant. These are tested in random order and the posterior fourchette is tested last as this area has a high probability of provocation.  Pain is rated on the Numerical Rating Pain Scale from 0-10, where 0 is no pain and 10 is the greatest pain one can imagine. The test is repeated during re-evaluation following procedural interventions.² From this assessment, the therapist can determine where symptoms are perceived versus where they can be provoked.³

o   Pelvic and visceral adhesions may be seen and detected with visceral manipulation techniques, although they lack validity, reliability, and effectiveness, it may prove to be a useful tool in the evaluation and treatment of this population.²

 

• Internal Palpation/Exam (vaginal):

o   An examination of the middle and deep pelvic floor muscles should then commence and is best conducted via transvaginal or transrectal palpation. From this exam, the clinician can evaluate the pelvic floor musculature for the presence of trigger points, spasm, vaginal vault size, symmetry, muscle activity, and muscle strength.²  Manual muscle testing, using the modified Oxford scale, is done to determine PFM strength and excursion.^2,8

o   A cleaned, well glove, and lubricated finger is used to enter the vaginal (or rectal) vault to assess presence of pain and vaginal/rectal coordination and strength (Please refer to Hand Washing Protocol for more details).

o   Common findings for patients with CPP and PFM tension myalgia include: tenderness of PFM, spasm of the PFM, trigger point presence, shortened muscles, overactive PFM, poor posture, and/or deconditioned pelvic floor muscles. With shortened muscles, pain and weakness may be present and will have a decreased ability to lengthen, elongate, or bulge their PFM downwardly, which is needed to allow voiding or penetration to occur without pain.² With pelvic floor muscle over activity, the musculature has tension at rest, and these patients are often unable to demonstrate much more of a contraction and will rarely show a release of the muscle between attempts at contraction.  Consequently, the attempt to contract the pelvic floor musculature will often be ineffective.³

§  The aforementioned possible findings of altered muscle activity can be evaluated with palpation, surface electromyography (sEMG), observation, and RUSI.

·         Surface Electromyography (sEMG): For diagnostic studies, objective determination of pelvic floor muscle over activity or under activity can be obtained through various techniques, one of which is sEMG. Either internal vaginal or rectal sensors or external superficial adhesive sensors may be used. The examination will likely reveal at least 3 of the 5 following findings: elevated and unstable resting baseline activity, poor derecruitment after contraction, poor return to baseline after contraction, spasms with sustained contractions, and poor overall recruitment.^2,3

·         Rehabilitative Ultrasonic Imaging (RUSI): Overuse of abdominal oblique muscles or valsalva maneuver during the execution of a PFM contraction may be seen on RUSI which may be worsening symptoms²

o   Less likely to be observed is under activity or weakness of PFM, yet still possible and should not be overlooked.²

 

 

·         Functional Outcomes:
It is important to recognize that no single measurement can capture the entire scope of pelvic floor symptoms or impairments; therefore, the use of health related quality of life measures as an adjunct to clinical examination and evaluation offers a more accurate means of demonstrating and understanding the impact of pelvic floor dysfunction, including vulvar pain, on a woman’s daily life. ²

o   Health-related quality of life questionnaires refer to a person’s total sense of well-being and consider multiple dimensions including: social, physical, and emotional health.

o   Vulvar Functional Status Questionnaire (VQ): provides a measure of physical function among women with vulvar pathology

o   Pelvic Organ Prolapse and Incontinence Sexual Function Questionnaire (PISQ): assesses the impact of POP or UI on the sexual function of sexually active women.²

Differential Diagnosis:

• Non-musculoskeletal gynecological and/or urological or colorectal disorders (i.e.: endometriosis) should be considered.¹⁹
• Hip pathology, lumbosacral radiculopathy, plexopathy, or peripheral neuropathy including pudendal neuralgia should also be examined in the differential diagnosis process.¹⁹
• Lumbar source of pain: Current reports of or a history of lumbar pain, pain located above the sacrum, decreased ROM in the lumbar spine, pain with lumbar motion, pain with palpation of erector spinae muscles, and negative PGP special testing should be examined as part of the differential diagnosis.
• Pelvic girdle pain: Pelvic girdle pain (PGP) is defined by pain experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joints (SIJ). PGP is a specific form of low back pain (LBP) that can occur separately or concurrently with LBP.  The pain may radiate in the posterior thigh and can occur in conjunction with/or separately in the symphysis, a similar location to that of vulvar region pain. PGP generally arises in relation to pregnancy, trauma, or reactive arthritis. The pain or functional disturbances in relation to PGP must be reproduced by specific clinical tests.²⁰
• Rupture of the symphysis pubis: A pubic symphysis rupture is characterized by tenderness and swelling over the symphysis pubis. Separations greater than 1 cm are considered to be symptom producing. Palpation of gapping in the joint may occur. Patients may report difficulty with ambulation. Patients may have PGP in addition to rupture.²¹
• Vulvar skin condition (such as lichens sclerosis)¹⁶
• Tumor or infectious process

"...

The main goal of physical therapy for pelvic pain is to rehabilitate the PFM by: increasing awareness and proprioception, improving strength, speed, endurance, and muscle discrimination, decreasing over activity and improving voluntary relaxation, increasing elasticity of the tissues at the vaginal opening, and decreasing the fear of penetration.¹⁰

Treatment should focus on the cause of the dysfunction, not just the source of pain. The goal of therapy is to address any musculoskeletal imbalances that are causing or perpetuating the pain.¹⁹

Patient Education:

Patient education must always occur first and is one of the most important factors in treating this population.³ Specifically, educating the patient about the physical therapy examination findings, the specific nature of their pain, and how treatment strategies correlate with improvement in their condition.^{2, 3} The role of the pelvic floor muscles in posture, sexual appreciation, bowel, and bladder control, physiology of micturition/defecation, proper bowel and bladder habits/techniques, proper postural techniques, role of hormonal changes, and proper skin care techniques should all be addressed.³  Education regarding proper posture and use of support devices such as lumbar rolls and perineal support cushions may be included. Recommended vulvar care practices such as: avoiding irritants, wearing only cotton underwear, and cleaning the area only with water may be provided to the patient.²  Furthermore, education to avoid provocating activities initially (i.e.: intercourse, tampon usage)  or changing positions with painful activities may also be warranted.^{12, 22} Finally, a comprehensive program should always include instruction in a home exercise program to promote patient/client independence and continuity of treatment.²

Manual Therapy:

Specific manual soft tissue mobilization techniques to address scar tissue, adhesions, trigger points, and to desensitize the tissue in this area should be utilized. Such techniques would include: scar mobilization, myofascial release, trigger point release, muscle energy techniques, strain-counterstrain, and joint mobilization.^{19, 22}  Passive and resistive stretching techniques are designed to improve blood flow and mobility to the pelvic and vulvar region, and normalize postural imbalances.²²  In either cases of over- or under-active PFM dysfunction, correction of spinal, hip, pelvic, sacroiliac joints, and coccyx dysfunction will help to balance the system and may improve some of the function and pain level experienced by the patient.  Correcting dysfunctional movement patterns, resolving neural tension, resolving pelvic visceral adhesions, and increasing abdominal strength are all important in this population.²

 

External Perineal Treatments: Skin rolling, external trigger point/myofascial release techniques, and scar mobilization to the affected regions around the pelvic and vulvar region can be useful.

Internal Treatments (intra-vaginal): Transvaginal manual techniques of the pelvic floor muscles have been used for the treatment of high-tome dysfunction of pelvic floor patients with CPP and IC, with symptoms remaining significantly improved after four and one half months.⁵  Trigger point release, myofascial release, stretching, manual scar mobilization, strength and coordination training of the pelvic floor musculature using digital tactile cueing, is also warranted in this population.⁵ Manual therapy techniques directed at the vaginal introitus can be useful for increasing vaginal entry space and desensitizing areas that are painful to touch.²²

Surface Electromyography (sEMG) Biofeedback:

Biofeedback with use of sEMG can be beneficial to facilitate a patient’s awareness of the activity in their pelvic floor muscles and facilitate pelvic floor muscle coordination and relaxation or downtraining as appropriate.^3,19  Biofeedback is a conditioning treatment whereby typically unknown information about a bodily function (pelvic floor muscle activity) is converted into simple auditory or visual cues so they can be voluntarily altered to become more efficient.²³

·         In the case of a patient with overactive PFM contributing to their pain, sEMG can be used to facilitate a reduction in the patient’s resting level of activity of the PFM. When the PFM improve in their resting level as demonstrated by decreased activity at rest, then PFM weakness may become more apparent.² This should then be addressed with pelvic floor muscle uptraining as described below. Home biofeedback can also be issued to the patient if needed for further training.

Rehabilitative Ultrasonic Imaging (RUSI):

Incoordination of the PFM, abdominal muscles or both may be observed with RUSI. Therefore, RUSI can be used to facilitate increased patient awareness of the inappropriate muscle activity to promote proper PFM and/or abdominal contraction and synergy.²

Therapeutic Exercise:

If there is imbalance of the muscles of the pelvic floor, trunk, and hips, the following therapeutic exercise strategies can be used: stretching of shortened musculature in and around the pelvis after pelvic obliquity correction and specific trunk stabilization exercises including transverse abdominis, multifidus, and pelvic floor musculature and breathing diaphragm.^{2, 22}

Modalities:  

Additional intervention options include modalities such as internal or external electrical stimulation, ultrasound, moist heat, and cryotherapy.² Heat applied to the lower pelvis and pelvic floor musculature can be facilitory of pelvic floor muscle relaxation.³ Heat and cold modalities can be helpful to promote pain management and relaxation of muscles.¹⁹

 

Transvaginal electrostimulation has been associated with a success rate of 50%, approximately with pain intensity being improved after 4 weeks post-treatment and remained after 30 weeks post-treatment in patients with CPP and interstitial cystitis symptoms.⁵ Furthermore, the use of pelvic floor electrical stimulation in patients with pelvic pain and pelvic floor muscle over activity has been reported to both reduce pain and increase muscle strength in patients with vulvar vestibulodynia.²⁵

 

Behavioral Retraining:

Retraining of proper bladder and bowel habits and techniques, as well as proper postural awareness is essential for long term management of pain in this population.³ Proper breathing strategies are also important in patients with pelvic pain. There is a normal synergy between the respiratory diaphragm and the pelvic floor muscles, in that during inhalation, the pelvic floor muscles descend and relax, while during exhalation the pelvic floor muscles return to their resting baseline. Patients should be taught that during rest, the pelvic floor muscles should be relaxed and the patient educated on ways to monitor pelvic floor muscle activity during the day so that the muscle tone in this area is not inadvertently raised at the end of the day.¹⁹

 

Frequency & Duration:

Typically, a patient with pelvic or vulvar pain is seen by the physical therapist for one visit per week for at least 8 to 12 weeks.¹²

Patient’s Discharge Instructions:

Patient’s instructions at discharge should include: continuation of and independence with home exercise program to promote independent symptom management, as well as independence with activity modification and postures to minimize pain as appropriate. Patients should follow up with their physician if symptoms progress or re-occur." 

 

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