Caroline Stone D.O.

(Hons),MSc(Ost),Med
[email protected]
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
dysfunction
Pelviperineology 27, 89-93.
Petros, P. E., & Ulmsten, U. I. (1990). An integral theory
of female urinary incontinence. Experimental and
clinical considerations. Acta
Obstet.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
[2325]. 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;76:267590.
24 Houghton AK, Wang C, Westlund KN. Do nociceptive signals from the pancreas travel in the dorsal
column? Pain 2001;89:20720.
25 Palecek J. The role of dorsal columns pathway in visceral pain. Physiol Res 2004;53(1):12530.
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):71
4-6., 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.