Provider Name & Treatment Location: Carminati, M. & Lahonda, L. (June 2023). Inspira Physical Therapy & Pilates, Brooklyn, NY.
Key Words: Superficial primary dyspareunia; pelvic floor physical therapy; TECAR therapy; Winback bracelet; pelvic floor hypertonicity
Summary (Abstract)
This case study describes the treatment of a 37-year-old patient assigned female at birth (AFAB) with a primary diagnosis of superficial primary dyspareunia, who underwent 7 pelvic floor physical therapy sessions incorporating the Winback TECAR therapy bracelet during the internal manual therapy portion of treatment.
Winback TECAR therapy delivers high-frequency electromagnetic waves (0.3 to 1.2 MHz) into the soft tissue structures of the pelvic floor region via a handheld bracelet, allowing greater patient comfort during internal treatment, increased effectiveness of manual therapy, and longer-lasting results for pain relief and soft tissue tightness.
Following introduction of Winback TECAR therapy, the patient demonstrated significant improvements in pelvic floor muscle (PFM) resting tone, decreased tenderness to palpation, improved connection and lengthening of the PFM during diaphragmatic breathing, and substantially reduced pain with sexual intercourse. By the sixth visit using TECAR, the patient reported minimal discomfort during intercourse and was very satisfied with the results.
Key take-away lessons:
- The Winback TECAR bracelet was applied to the treating clinician’s gloved forearm muscle belly (not directly to the patient), creating a circuit that delivered RES-mode energy through the clinician’s hands during internal pelvic floor manual therapy.
- TECAR therapy provided a sensation of relaxing warmth that offered an analgesic benefit and appeared to reduce fear and improve relaxation during internal treatment.
- Improvements gained from session to session were better maintained (carryover) after TECAR was introduced, compared to prior sessions of manual therapy alone where gains were difficult to sustain.
- A graduated treatment-position progression (hook-lying to modified prone) was used as the patient’s tolerance and symptoms improved.
Introduction
Winback TECAR therapy has emerged with innovative technology via a handheld bracelet, allowing pelvic floor physical therapists to administer high-frequency electromagnetic waves (0.3 to 1.2 MHz) into soft tissue structures of the pelvic floor region for both male and female patients. This technology allows for greater patient comfort during treatment, increased effectiveness of manual therapy, and longer-lasting results for pain relief and soft tissue tightness.
This case study focuses on a 37-year-old patient assigned female at birth with a primary diagnosis of superficial primary dyspareunia and the use of 7 pelvic floor physical therapy sessions incorporating the Winback TECAR therapy bracelet during the internal manual therapy portion of care.
Background
Both treating physical therapists are licensed physical therapists in New York State and received pelvic floor physical therapy training through Herman & Wallace. The physical therapy office where the patient received care is a private office where all treatment sessions are 1 hour in length and the patient spends the entire treatment with the same licensed physical therapist. The patient was referred to pelvic floor physical therapy by a pelvic physiatrist.
Patient Information / Diagnosis
Demographics: 37-year-old patient assigned female at birth (AFAB).
Diagnosis: Superficial primary dyspareunia (pain with sexual intercourse upon initial penetration).
Relevant Medical/Family History: History of septum removal surgery due to uterine didelphys. History of IBS and food allergies. No active urinary tract infections, yeast infections, or similar diagnoses. No urinary incontinence; normal bowel movements.
Psychosocial Factors: Psychosocial factors influencing pain were discussed and addressed with the patient. The patient receives regular psychotherapy and has addressed potential psychosomatic influence with her provider.
Activity Level: Regular Barre classes and walking prior to starting physical therapy.
Chief Complaint: Pain with sexual intercourse upon initial penetration, significantly affecting quality of life.
Clinical Findings
Subjective
Patient’s main complaint was pain with sexual intercourse upon initial penetration that significantly affected her quality of life.
Objective
Static postural analysis: forward head, rounded shoulder posturing, downward-rotated shoulders (bilateral), hip thrust forward posture with posterior pelvic tilt, bilateral knee valgus, and decreased bilateral arches.
Manual muscle testing (MMT): difficulty connecting to deep core muscles; hip abduction weakness 3/5 bilaterally; hip external rotation 3+/5 bilaterally.
| Measure | Findings |
| Hip Active ROM (Flexion / IR / ER) | 105° / 15° / 80° (bilateral) |
| Hamstring Flexibility (90/90 test) | 35° (bilateral) |
Pelvic floor assessment: external observation revealed no tissue irregularity in the perineal region and labial tissues. Internal palpation revealed no palpable scar tissue from the prior uterine didelphys septum removal, increased tone in the 1st and 2nd pelvic floor muscle (PFM) layers (bilateral), tenderness to palpation (TTP) of the 2nd PFM layer (bilateral), and trigger points along the ischiocavernosus muscles and superficial perineal membranes (bilateral).
| Measure | Findings |
| Pelvic Floor MMT (PERFECT Score) | 3/5 (bilateral) |
| Endurance | 2-3 seconds |
| Quick Contractions | 3 quick contractions at 3/5 strength; 4 one-second quick contractions |
| Reverse Kegel (Bear-Down) | Unable to perform |
Detailed Treatment, Timeline, and Outcome
1. Timeline
The patient was first asked to stop participating in Barre classes for the initial period of physical therapy treatment, which helped reduce a large amount of the hypertonicity present in the pelvic floor musculature. Following an initial course of pelvic floor physical therapy using internal manual releases, education on pelvic floor muscle elongation (“reverse Kegels”), and diaphragmatic breathing with visual imagery (an “elevator” guiding the breath to the pelvic floor to release tension), the patient was then seen for 7 visits incorporating the Winback TECAR therapy bracelet, with significant improvements reported.
2. Diagnostic Assessment
Diagnostic methods: clinical interview, static postural analysis, manual muscle testing, hip active range of motion testing, hamstring flexibility testing (90/90), and internal pelvic floor assessment (external observation, internal palpation, and pelvic floor MMT via PERFECT score).
Diagnosis: superficial primary dyspareunia associated with pelvic floor muscle hypertonicity, tenderness to palpation of the 2nd PFM layer, trigger points along the ischiocavernosus muscles and superficial perineal membranes, and impaired ability to relax/lengthen the pelvic floor (inability to perform reverse Kegel).
Prognostic characteristics: not specified beyond the progressive improvements documented across the 7 TECAR-incorporated sessions.
Therapeutic Intervention
1. Type of Intervention
Prior to incorporating Winback TECAR therapy, the patient’s treatment included internal manual releases, education on pelvic floor muscle elongation (“reverse Kegels”), and diaphragmatic breathing with visual imagery (an “elevator” guiding the breath to the pelvic floor) with the goal of releasing tension. The patient was responding well to treatment and reported significant additional improvement after Winback TECAR therapy was introduced, which was also noted by both treating physical therapists.
2. Protocol Steps
- Initially, the Winback TECAR bracelet was used with the bracelet placed on the treating physical therapist’s forearm muscle belly of the treating hand. Disposable medical exam gloves were worn on both hands of the treating physical therapists.
- The patient was treated in a hook-lying position. When improvement of symptoms was noted, the patient’s treatment position was progressed to a modified prone position as well (patient on her elbows with pillows under the belly).
- In the hook-lying position, the ground plate was placed under the buttock and the physical therapist utilized a bracelet on the forearm muscle belly of the same side as the patient’s PFM being treated. Treatment was then repeated on the opposite side after glove changes and replacement of the Winback TECAR bracelet on the opposite forearm muscle belly of the treating hand.
- In the modified prone position, two pillows were placed under the belly and the ground plate was placed under the belly. In this position, internal manual therapy was provided rectally with focus on release of the deep transverse perineal musculature.
- Settings: RES mode at 30% intensity. Each side of the PFM was treated for approximately 10-15 minutes, with the entire Winback TECAR treatment totaling at least 30 minutes. The focus of internal treatment was on the deep transverse perineal muscle, ischiocavernosus, and levator ani muscle on both sides.
- Home exercise program: diaphragmatic breathing with focus on lengthening of the PFM on inhalation (2×8), and use of a pelvic wand to stretch the 2nd layer of the PFM and address tender points in the 3rd layer of the PFM.
TECAR Parameters
| Setting | Duration | Intensity | Notes |
| RES (Resistive Energy Transfer) — via bracelet on clinician’s gloved forearm | 10-15 minutes per side; total session ≥30 minutes | 30% | Applied during internal manual therapy in hook-lying, then progressed to modified prone position as tolerated. |
3. Changes in Therapeutic Intervention
During the initial course of pelvic floor physical therapy (prior to TECAR), the patient reported a decrease in pain and decreased sensation of tension in the PFM during sessions; however, symptoms would return and it was challenging to maintain results from session to session. After initiation of Winback TECAR therapy during the internal manual therapy portion, the patient responded very well and demonstrated carryover of gains from session to session. After the third TECAR session, the patient reported intercourse felt much more comfortable, though still with some noticed discomfort. During following sessions, the patient demonstrated improved resting tone of the 1st and 2nd PFM layers, decreased TTP in the levator ani muscles, and improved connection and lengthening of the PFM during diaphragmatic breathing.
Treatment Protocol and Follow-Ups
Session Frequency / Techniques: 7 visits incorporating the Winback TECAR bracelet during internal manual therapy, following an initial course of manual-therapy-only pelvic floor PT; after the 6th TECAR visit, the patient was advised to schedule an appointment once every two weeks for the following month and to continue her home exercise program and pelvic wand use as needed.
Clinician- and patient-assessed outcomes: Patient-reported pain with intercourse, sensation of PFM tension, and comfort during treatment; clinician-assessed PFM resting tone, tenderness to palpation, and PFM connection/lengthening during diaphragmatic breathing.
Important follow-up diagnostic and other test results: Not specified beyond clinical/subjective progression described in Results.
Intervention adherence and tolerability: Patient continued sexual intercourse with her partner throughout treatment and reported progressive improvement in comfort; no difficulties with tolerability reported.
Adverse and unanticipated events: None reported.
Results after Treatment Completed
Significant improvements were found after initiation of Winback TECAR therapy during the internal manual therapy portion of pelvic floor physical therapy treatment. The patient responded very well to TECAR and demonstrated carryover and gains from session to session — in contrast to the manual-therapy-only phase, where gains were difficult to maintain between sessions. After the third TECAR session, intercourse with her partner felt much more comfortable, though with some noticed discomfort remaining. During subsequent sessions, the patient demonstrated improved resting tone of the 1st and 2nd PFM layers, decreased tenderness to palpation in the levator ani muscles, and improved connection and lengthening of the PFM during diaphragmatic breathing. After the 6th visit with TECAR, the patient reported minimal discomfort during sexual intercourse and was very happy with the results.
Discussion
Treating dyspareunia can be very challenging at times. Patients might have difficulty relaxing their pelvic floor musculature (PFM) in anticipation of pain or discomfort, and may also experience difficulty controlling pelvic floor function (contraction, relaxation, bearing down) due to increased tone.
The use of Winback TECAR therapy in treating dyspareunia offers patients a sensation of relaxing warmth/heat that alone provides an analgesic benefit. Winback TECAR therapy provides a diathermic effect on tissue, resulting in increased vascularization of the target area. According to Clijsen et al., there is a significant change in intramuscular blood flow with the use of Winback TECAR therapy in RES mode. Winback TECAR treatments use high-frequency electromagnetic waves that contribute to reduction of muscle spasms and contractions, improve blood flow and muscle oxygenation, and result in decreased pain.
Using TECAR modality for treatment of dyspareunia offers patients the opportunity to respond to internal treatment with less fear, improved relaxation, improved ability to connect to pelvic floor muscles, longer-lasting results between treatments, decreased muscle spasms, and reduced pain with fewer visits compared to treatment of the same condition without use of Winback TECAR therapy. Limitations of this case report include its single-patient design and the absence of standardized outcome measures (e.g., FSFI) at intake and discharge. Take-away: this case study supports the use of Winback TECAR therapy as an adjunct to internal pelvic floor manual therapy for superficial primary dyspareunia.
Patient Perspective
The patient reported that after the third session incorporating Winback TECAR therapy, intercourse with her partner felt much more comfortable, although some discomfort was still noticed. After the sixth TECAR session, she reported minimal discomfort during sexual intercourse and was very happy with the results.
Informed Consent
Not specified in source documentation. Patient consent for use of de-identified clinical data in this case report should be obtained and documentation made available on request.