Caroline Stone D.O.(Hons),MSc(Ost),Med

caroline@yourosteopath.com.au

Courses: www.visceral-osteopathy.com.au

Osteopathic approach to chronic

pelvic and perineal pain

What is

Osteopathy?

What is Osteopathy

2006

Osteopathy is an established recognized system of

healthcare which relies on manual contact for diagnosis and

treatment. It respects the relationship of body, mind and

spirit in health and disease; it lays emphasis on the

structural and functional integrity of the body and the

body's intrinsic tendency for self-healing.

Osteopathic treatment is viewed as a facilitative influence to

encourage this self regulatory process.

Pain and disability experienced by patients are viewed as

resulting from a reciprocal relationship between the

musculoskeletal and visceral components of a disease or

strain.

Medicare

Allied Health Initiative

Osteopaths, amongst others are now able to provide healthcare under MEDICARE for those patients on an EPC (enhanced primary care plan), for up to 5 sessions per annum

Medicare provides rebates under enhanced primary care plans for patients suffering from a chronic health complaint who receive treatment from osteopaths after referral from their GP.

Osteopaths see patients with:

Endometriosis

Interstitial cystitis

Irritable bowel

syndrome

Levator ani syndrome

Pelvic floor tension

myalgia

Post-surgical

complications

Vulvar vestibulitis and

Vulvodynia

Dysparunia

Bladder and rectal

incontinence

Dysmenorrhoea

Post partum pain

syndromes

What is the osteopathic contribution? View that understanding of 3D

organ biomechanics, and its influence on neural reflexes and integration is currently lacking

The role of peritoneum in movement mechanics is missed

The subject of ‘organ slide’ is undervalued, and has a relationship to adhesion formation, and management

That organ movements is related to physiological function (for example physiological peristalsis and threshold levels of organ responsiveness to stretch

Smooth muscle work is relevant as well as somatic muscle work, and fascia and peritoneal ligaments are informative propripoceptively and to other neural reflexes

Hypervigilance / central sensitisation / involvement of higher centres could still be influence by afferent factors, especially from mechanoreceptors and shear force detection in the periphery

That palpation is an important diagnostic and therapeutic component

Integrated approach in chronic pelvic

pain management

Respecting the presence of pathology, one can work with

a variety of factors within the visceral and somatic fields

and contribute to symptom resolution

In the absence of pathology, osteopaths can offer a

unique interpretation of many clinical scenarios that seem

to challenge orthodox practise

One key contribution is to view the pelvic contents (and

other body areas) and their physiological function as an

integrated whole – not as a series of separate parts

3D movement

How does the body move in 3D? Think

cavities and contents as well as skeletal

Global mechanical links

Integrative models of management

• The body cavities are treated as contiguous with the locomotor system, and the visceral contents have a reciprocal biomechanical relationship with the musculo-skeletal system

Continued...

3D movement includes visceral

motion, fascial mobility, vascular

and hydrostatic forces, and

general postural factors which

include organ slide as well as

muscular support and neuro-

musculo-skeletal integrity

3D movement testing

Appreciating the complexity of

interaction of kinetic chains

passing through differing joint

and soft tissue structures (and

their neuro-mechanical co-

ordination) means building

fascial, peritoneal, connective

tissue and visceral components

into whole body mechanics – as

part of normal MSS and normal

VISCERAL functioning

General visceral approach

Examination

Flexibility within solid organs e.g. liver

tissue, renal tissue etc

Flexibility in capsule or ‘membranes’

Flexibility in hollow organs e.g. Fallopian

tubes, ureters, GIT, bile duct, urethra,

uterus

Flexibility in supportive ligaments

Flexibility with points of connection to

body cavities and body walls / bony

structures

Shear force structures (esp in GIT) contribute to pain perception

Visceral pain pathways may be influenced by physical mobilisations to abnormally tense visceral myofascial structures

PETERSEN, P., GAO, C., ARENDT-NIELSEN, L., GREGERSEN, H., & DREWES, A. (2003). Pain Intensity and Biomechanical Responses During Ramp-Controlled Distension of the Human Rectum. Digestive Diseases and Sciences, 48(7), 1310-1316.

Limbic associated pelvic pain

Fenton (2007)

Limbic associated pain may explain many factors associated with pelvic pain

Is associated with the following types of condition: Endometriosis

Interstitial cystitis

Irritable bowel syndrome

Levator ani syndrome

Pelvic floor tension myalgia

Vulvar vestibulitis and

Vulvodynia

Gives insight into how osteopathic treatments can impact on these conditions / syndromes

LAPP

Patients have hyperalgesia and allodynia

Limbic dysfunction manifests as:

Increased sensitivity to pain afferents from pelvic

organs

Abnormal efferent innervation of pelvic musculature,

both visceral and somatic

Pain afferents from tonic pelvic musculature then feed

back into hypervigilant limbic system, perpetuating

cycle

Management of limbic hypervigilance

(and ‘central sensitisation issues)

Medical AND cognitive therapy is required to reduce limbic sensitivity

Osteopaths can provide manual relief of pelvic muscular dysfunction, as well as using cognitive methods as they discuss findings and palpatory experiences with the patient during treatment

All of the musculo-skeletal components relating to pelvic pain that were listed before can potentially feed into the limbic system disturbance

Where is it?

It is on the underneath of the pelvis between the bones of the pelvis

This is the ‘traditional’ view, but no the best one!

Its not a level floor….

Pelvic floor is a series of spirals and loops

Relates to orificial function, integration with abdomen and gait cycles

Is influenced by coccygeal function and other pelvic articulations including the hips and lower limbs

Pelvic floor expressions…

The pelvic floor is

involved in many

different ‘emotions’

It expresses many

different actions,

activities and

feelings

throughout the day,

and

with many different

problems

Pelvic floor and pelvic organ integration

Organ movement and pain presentations

Uterine mobility is controlled by a) vaginal mechanics and

by b) other ligaments and fascia, and c) the pelvic floor

(Petros & Ulmsten 1997; Harris 1990, Norton 1993) For a long time an integrated understanding of the integrated mechanics

of the pelvis has been a long way off (Lewis-Wall 1991).

The utero-sacral ligaments contain smooth muscle and hormone

receptors (Mokrzycki 197)

Uterosacral problems can cause pain (Petros 1996; Koninckx 1997)

Venous congestion (pelvic varicosities) is associated with pelvic pain

(Sichlau 1994; Gupta 1994)

Vulvo-vaginal pain is linked to pudendal neuralgia and pelvic floor function

(Glazer 1997)

Uterosacral and pubovesical ligaments

act in concert with levator plate

Levator plate

mobility

influences vagina

and uterus, as

well as bladder

movement

Petros, P. E., & Swash, M. (2008). The Musculo-Elastic Theory of anorectal function and dysfunctionPelviperineology 27, 89-93.

Petros, P. E., & Ulmsten, U. I. (1990). An integral theory of female urinary incontinence. Experimental and clinical considerations. ActaObstet.Gynecol.Scand.Suppl., 153:7-31., 7-31.

Uterine - cervical ligaments

Pubo-vesical

(Pubo-vesical)

Transverse cervical

Parametrium

Utero-sacral

Cervix is at the ‘hub’ of the pelvis

DeLancey, J. O. (1988). Structural aspects of the extrinsic continence

mechanism. Obstet.Gynecol., 72, 296-301.

3 ‘distinct’ movement regions

General visceral biomechanics

Cervical and uterine movements and

pressures in intercourse

Cervix, although most anchored, should be mobile

Prostate and seminal vesicle motion related

to rectal mechanics

Pubic, hip, sacral and coccyx

influences

Direct organ work is useful

But needs to be supplemented by articulatory and myofascial work to structures where visceral and pelvic floor ligaments insert

Prostate – external mobilisation via levator plate and perineum (not PR)

Pubis – pubovesical

Obturator internus - Arcus

tendinus and levator plate

Hip articulations (and lower

limb kinetic patterns) –

obturator interus

Sacro-coccygeal and sacro-

iliac articulations – levator

plate and utero-sacral

ligaments

Obturator combined releases Accessing obturator

space inferior to adductor mass

Combines with hip mobilisation

As well as supra-pubic bladder, uterine or general pelvic fascial release

Effective contact for global fluid pumping and drainage

Lower urinary tract function – musculo-skeletal

‘functional disturbances’ and limbic integration

All of these final boxes have relevance for organ

support and for tissue / organ 'irritability'

Spinal facilitation

Intact central

nervous system

pelvic articulations

Pelvic floor

mechanics

organ biomechanics

pelvic connective

tissue

Efficient bladder and

urethral support

lumbo-sacral foramenae

(entrapment)

pudendal nerve

(obstetric injury)

(scarring)

peripheral neuropathy

Intact peripheral

nervous system

Higher center

sensitisation

Tonicity of

pelvic organ

musculature

Cognitive

behavioural

components

Neural reflexes

DeLancey, J. O. (1988). Structural aspects of the extrinsic continence mechanism. Obstet.Gynecol., 72, 296-301.

Many reflexes operating between component parts to the sacral micturition centre, and from there to higher centres

These have been expanded on, and the role of smooth muscle and myofascial / connective tissues has to be brought into that debate, especially in the light of new insights to chronic visceral pain

Reflex relationships

Recently it has become apparent that visceral pain

information may not follow the conventional pathway thought

to convey nociceptive information, the spinothalamic tract

(STT). Rather the dorsal columns, thought to convey touch

and proprioceptive information is a major pathway for

visceral sensory input projecting to the thalamus

[23–25]. Philip D. Austin, MSc,*† and Sarah E. Henderson, PhD*: submitted

to Pain Medicine

23 Al-Chaer ED, Lawand NB, Westlund KN, Willis WD. Pelvic visceral input into the nucleus gracilis is

largely mediated by the postsynaptic dorsal column pathway. J Neurophysiol 1996;76:2675–90.

24 Houghton AK, Wang C, Westlund KN. Do nociceptive signals from the pancreas travel in the dorsal

column? Pain 2001;89:207–20.

25 Palecek J. The role of dorsal columns pathway in visceral pain. Physiol Res 2004;53(1):125–30.

Organ slide

Peritoneal influence on GIT

tract mobility is understood

But under appreciated in

urogenital work – in a

therapeutic sense

Broad ligament interface

with intestines, or visceral

peritoneum of bladder in

males is important

Role in adhesion

management needs

furthering

Kolecki, R. V., Golub, R. M., Sigel, B., Machi, J., Kitamura, H., Hosokawa, T., et al. (1994). Accuracy of viscera slide detection of abdominal wall adhesions by ultrasound. Surg.Endosc., 8(8), 871-874.

Tan, H. L., Shankar, K. R., Ade-Ajayi, N., Guelfand, M., Kiely, E. M., Drake, D. P., et al. (2003). Reduction in visceral slide is a good sign of underlying postoperative viscero-parietal adhesions in children. J.Pediatr.Surg.2003.May;38(5):714-6., 38(5), 714-716.

Physiological effects:

Uterine movements in endometriosis

Fujiwara, T., Togashi, K., Yamaoka, T., Nakai, A., Kido, A., Nishio, S., et al. (2004). Kinematics of the uterus: cine mode MR imaging. Radiographics.2004.Jan-Feb;24(1):e19.Epub.2003.Nov.3., 24(1), e19. Epub 2003 Nov 2003.

Types of treatment

Floating ilia and pelvic inlet / outlet

balancing, and dorso-lumbar techniques

Potential examination and treatment

sites

Sitting renal release, and ureters

Pelvic floor components

Practical: Pelvic floor contacts, and

posterior sidelying contacts

Male urogenital

Pelvic visceral components

Local pelvic tissues

Surrounding tissues can

tense onto the outside of

the organs

This can interfere with

circulation, general organ

movement, stretch and

elasticity

Leading to previously

mentioned problems

Urachus, umbilical ligaments and

supra-pubic tissues

Very important for

abdominal wall

integration

Superior and anterior

support of bladder apex

Inguinal, lower abdominal

and caesarean surgeries

have implications

Supra-pubic bladder and uterus

Useful for preparing

access to pubo-vesical

ligament space

Helpful for round

ligaments and inguinal

relationships

Accessory movement of

ilium can limit discomfort

of techniques in

sensitised patients

PR and PV accessed tissues

Global uterine release

Sidelying of supine

combined technique

Looks at uterus, broad

ligaments, fallopian tubes

Can help access cervical

ligaments and some

influence on utero-sacral

techniques

Incorporates small intestine

into focus and can move up

to ROM as required

Global technique 2

Posterior hand contact enables focus to pass into posterior pelvis

round ligament and inguinal ring,

deep uterine and fallopian tube assessment

Brings in ovarian and iliac fossa relationships

Effective for integrating caecum and sigmoid into e.g. broad ligament and fallopian tubes as well

Fallopian tube dynamics

Fimbriae

Ovarian fold suppleness

Broad ligament dynamics

Fallopian peristalsis

Fluid dynamics – peritoneum

Ampulla dynamics

Relations to intestines, caecum and sigmoid etc

Studies 1: Fenton BW, Palmieri PA, Durner C, Fanning J. Quantification of abdominal

wall pain using pain pressure threshold algometry in patients with chronic pelvic

pain. Clin J Pain. 2009 Jul-Aug;25(6):500-5. PubMed PMID: 19542798.

2: Srinivasan AK, Kaye JD, Moldwin R. Myofascial dysfunction associated with

chronic pelvic floor pain: management strategies. Curr Pain Headache Rep.

2007 Oct;11(5):359-64. Review. PubMed PMID: 17894926.

3: Jarrell J. Myofascial dysfunction in the pelvis. Curr Pain Headache Rep. 2004

Dec;8(6):452-6. Review. PubMed PMID: 15509458.

4: FitzGerald MP, Kotarinos R. Rehabilitation of the short pelvic floor. I:

Background and patient evaluation. Int Urogynecol J Pelvic Floor Dysfunct.

2003 Oct;14(4):261-8. Epub 2003 Aug 2. Review. PubMed PMID: 14530839.

Studies 5: Weiss JM. Pelvic floor myofascial trigger points: manual therapy for interstitial

cystitis and the urgency-frequency syndrome. J Urol. 2001 Dec;166(6):2226-31.

PubMed PMID: 11696740.

6: Gambone JC, Reiter RC. Nonsurgical management of chronic pelvic pain: a

multidisciplinary approach. Clin Obstet Gynecol. 1990 Mar;33(1):205-11.

PubMed PMID: 2311316.

7: Slocumb JC. Chronic somatic, myofascial, and neurogenic abdominal pelvic

pain. Clin Obstet Gynecol. 1990 Mar;33(1):145-53. Review. PubMed PMID:

2178831.

8: Slocumb JC. Neurological factors in chronic pelvic pain: trigger points and the

abdominal pelvic pain syndrome. Am J Obstet Gynecol. 1984 Jul 1;149(5):536-

43. PubMed PMID: 6234807.

Studies 9: Simons DG, Travell JG. Myofascial origins of low back pain. 3. Pelvic

andlower extremity muscles. Postgrad Med. 1983 Feb;73(2):99-105, 108.

PubMed PMID: 6823467.

10: Tu FF, Fitzgerald CM, Kuiken T, Farrell T, Norman Harden R. Vaginal

pressure-pain thresholds: initial validation and reliability assessment in healthy

women. Clin J Pain. 2008 Jan;24(1):45-50. PubMed PMID: 18180636.

11: Tu FF, Fitzgerald CM, Kuiken T, Farrell T, Harden RN. Comparative

measurement of pelvic floor pain sensitivity in chronic pelvic pain. Obstet

Gynecol. 2007 Dec;110(6):1244-8. Erratum in: Obstet Gynecol. 2008 Feb;111(2

Pt 1):454. Norman, Harden R [corrected to Harden, R Norman]. PubMed PMID:

18055716.

12: Shishido K, Peng Q, Jones R, Omata S, Constantinou CE. Influence of pelvic

floor muscle contraction on the profile of vaginal closure pressure in continent

and stress urinary incontinent women. J Urol. 2008 May;179(5):1917-22. Epub

2008 Mar 18. PubMed PMID: 18353401.

Studies 13: Thompson JA, O'Sullivan PB, Briffa NK, Neumann P. Assessment of

voluntary pelvic floor muscle contraction in continent and incontinent women

using transperineal ultrasound, manual muscle testing and vaginal squeeze

pressure measurements. Int Urogynecol J Pelvic Floor Dysfunct. 2006

Nov;17(6):624-30. Epub 2006 Mar 11. PubMed PMID: 16532264.

14: Oyama IA, Rejba A, Lukban JC, Fletcher E, Kellogg-Spadt S, Holzberg AS,

Whitmore KE. Modified Thiele massage as therapeutic intervention for female

patients with interstitial cystitis and high-tone pelvic floor dysfunction. Urology.

2004 Nov;64(5):862-5. PubMed PMID: 15533464.

15: Peters KM, Carrico DJ. Frequency, urgency, and pelvic pain: treating the

pelvic floor versus the epithelium. Curr Urol Rep. 2006 Nov;7(6):450-5. Review.

PubMed PMID: 17052440.