Pelvic Pain: An Osteopathic Perspective

1. Pelvic Pain: An Osteopathic Perspective Anita Showalter, D.O., FACOOG (D) Dean of Clinical Sciences, College of Osteopathic Medicine Associate Professor and Chair, Women’s Health Pacific Northwest University of Health Sciences

2. Objectives • Discuss osteopathic philosophy in patient care • Discuss the osteopathic approach to pelvic pain • Review of pelvic anatomy • Case presentations

3. Osteopathic Philosophy • The body is a unit; the person is a unit of body, mind and spirit. • The body is capable of self regulation, self-healing and health maintenance. • Structure and function are reciprocally interrelated. • Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the inter-relationship of structure and function. Foundations for Osteopathic Medicine

4. The Founder of Osteopathic Medicine: A.T. Still “The Osteopath should find health. To find health should be the object of the doctor. Anyone can find disease.” A.T. Still, Philosophy of Osteopathy

5. Somatic Dysfunction Definition: Impaired or altered function of related components of the somatic (body framework) system: Skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic and neural elements. Somatic dysfunction is treatable using osteopathic manipulative treatment. • Atlas of Osteopathic Techniques, 2nd edition, page 4

6. Osteopathic Treatment • Application of manual techniques to somatic dysfunction • Myofascial-articular • Visceral-autonomic • Somato-visceral • Viscero-somatic • Techniques • Articular • Myofascial

7. Principles of Fascia • At the time of early dissection, was thought to be an organ system • Preservatives changed the properties of fascia and its importance was not realized • Fascia has properties of strength and resilience • Fascia can be influenced • Fascia has a memory that connects to traumatic incidents • Surgery can cause fascial strains if incisions are not carefully reapproximated • Trauma can cause various fascial strain patterns

8. The Fascial Being

9. Patient History • History of trauma • MVA’s • Falls • Childbirth • Rape • Work • Strain patterns • Repetitive trauma

10. Gynecologic Exam • Is the cervix in the usual position • Pain with insertion of the speculum? • Initial • Deep • Bimanual • Uterus midline? • Adnexal tension/laxity?

11. Osteopathic Examination • Structural screening exam • Look for areas of asymmetry • Tissue texture changes • Tension • Bogginess • Turgor • Heat • Red reflex

12. Treating the Patient • Rule out any emergent or urgent conditions requiring immediate medical or surgical intervention • Do appropriate imaging studies • Do a structural exam looking for somatic dysfunction or possible visero-somatic or somato-visceral conditions • Explain rationale for OMT and treat patient on a trial basis

13. Patient Follow Up • Somatic dysfunction successfully treated may feel worse for several hours to a week – warn the patient! • Successful treatment will then show improvement. Chronic conditions will recur over time. • Each successful treatment will show increasing improvement and last for a longer period of time. • Dosing of treatments is aimed at having the patient return at about the time symptoms recur and see progressively longer intervals between treatments.

14. Problems of a Visceral Origin • Viscero-somatic problems will respond initially but will quickly return within hours. • If the treatment is not improving the patient’s symptoms, look for other causes. • If imaging studies and laboratory are negative, consider scheduling a diagnostic laparoscopy. • Patients with significant somatic dysfunction that did not get better with OMT will often improve for 3-4 months after diagnostic laparoscopy, then the symptoms tend to recur.

15. Anatomy Review

16. Anatomy Take Home Points • Midline organs should be midline • Paired organs should be symmetric • Restrictions in the surrounding tissues and fascia may lead to tissue texture changes and pain • There may be viscero-somatic and somato-visceral reflexes at play in pain syndromes

17. Case #1 – History of Chief Complaint • 42 year old with a 2 year history of intermitent vaginal burning and pain • Frequent dyspareunia • Treated numerous times for vaginal yeast without improvement • Biopsy negative for pathologic changes

18. Case #1 – Structural Exam • ASIS low on right • Outflare of right ilium, inflare of left • Pubic shear low on right • Sacral torsion • Lumbar rotation • Tissue texture changes in the thorax • Vulva visually red. Tender areas in the vagina along the levators on the right.

19. Case #1 - Treatment • External somatic findings treated. • Vaginal tender points treated with counterstrain (positioning for tissue changes) • Redness dissipated while treating! • PT for individualized exercises • Continue treatments every 4 weeks • Patient is symptom free most of the time

20. Case #2 – History of Chief Complaint • 44 year old female with a four year history of progressively severe pelvic pain • Was treated with a TAH for endometriosis 4 years earlier • When pain did not resolve, one ovary was removed. Later the other was as well. The pain persisted. No hormones were given because of the endometriosis. • First patient visit, patient was sobbing in the fetal position unable to talk normally

21. Case #2- Surgical Treatment • The patient was so acute that despite negative ultrasound, I decided to do a diagnostic laparoscopy. She would barely let me touch her on the first visit, so OMT was held off. • Massive adhesions of the small bowel to the anterior abdominal wall were left alone. • Other adhesions were from the bowel to the vaginal cuff and bladder and were taken down. No active endometriosis was seen.

22. Case #2 – Osteopathic Examination • The patient’s pain was somewhat relieved by the surgery. She allowed manipulation after. • The patient was noted to have a vertical AND an anterior/posterior shear (unusual finding). • There was tenderness in the suprapubic fascia • Sacral torsion noted • Lumbar rotation noted

23. Osteopathic Treatment • Correction of the pubic shear brought the most pain relief, especially the AP component. • Myofascial release of the suprapubic tissues and deep traction to prevent adhesion reformation were taught to the patient to do at home. • Patient was seen weekly for treatment and managed with narcotics for pain. • Patient was sent for prolotherapy on the pubic symphysis and sacroiliacs bilaterally. Had significant pain with the first treatment, and significant improvement with the second.

24. Conclusions • Pain management may often require a multiple disciplinary approach for successful treatment. • Sometimes, symptoms of somatic dysfunction mimic other medical conditions prolonging successful diagnosis and treatment. • Being aware of the possibility of somatic dysfunction in pain syndromes will lead to quicker diagnoses and prevent unnecessary intervention and diagnostic studies.

25. Contact me: ashowalter@pnwu.org

26. References • Interactive Pelvis and Perineum • Primal Pictures, Inc. • www.primalpictures.com • An Osteopathic Approach to Diagnosis and Treatment, Eileen L Di Giovanna, Stanley Schiowitz, 1991. J.B.Lippincott • Progressive inhibition of neuromuscular structures (PINS) technique, DJ Dowling ,J Am Osteopath Assoc, May 2000; 100: 285 - 298. • An Osteopathic Approach to Treating Women With Chronic Pelvic Pain, Melicien A. Tettambel, J Am Osteopath Assoc, Sep 2005; 105: S20 - S22. • Protocols for Osteopathic Manipulative Treatment (OMT).Revised July 1998. http://www.txosteo.org/Documents/OMT_protocols.pdf • Maigne JY, Chatellier G, Faou ML, et al. The treatment of chronic coccydynia with intrarectal manipulation: a randomized controlled study. Spine. Aug 15 2006;31(18):E621-7. [Medline]. • Foye PM. Finding the causes of coccydynia (coccygeal pain). J Bone Joint Surg Br [serial online]. January 18, 2007;Accessed April 16, 2007. Available at http://www.jbjs.org.uk/cgi/eletters/88-B/10/1388. • Foye PM. Ganglion impar injection techniques for coccydynia (coccyx pain) and pelvic pain. Anesthesiology. May 2007;106(5):1062-3; author reply 1063. [Medline]. • OMM Considerations in Patients with Chronic Pain.Michael Kuchera, DO. JAOA Supplement 4 Vol 105 No 9 Sept 2005 S29

27. References (cont) • Osteopathic Considerations in Systemic Dysfunction, Second Edition, Michael & William Kuchera • Efficacy of high-velocity low-amplitude manipulative technique in subjects with low back pain during menstrual cramping. David Boesler, DO. JAOA Vol 93 No2 February 1993 203 • Manipulation for Dysmenorrhea. Mary Elizabeth Hitchcock, D.O. JAOA Vol. 75, June 1976 • Tettambel, M. Gynecology. In Ward, RC, ed. FOUNDATIONS FOR OSTEOPATHIC MEDICINE, 2nd ed. Philadelphia, PA. Lippincott, Williams & Wilkins;2003;409-419. • Tettambel, M. Obstetrics. In Ward, RC,ed. FOUNDATIONS FOR OSTEOPATHIC MEDICINE, 2nd ed. Philadelphia, PA. Lippincott, Williams & Wilkins; 2003; 450-461. Hodges SD, Eck JC, Humphreys SC. A treatment and outcomes analysis of patients with coccydynia. Spine J. Mar-Apr 2004;4(2):138-40. [Medline]. • Maigne R. Diagnosis and treatment of pain of vertebral origin: a manual medicine approach. Baltimore: Williams & Wilkins, 1996:339–40. • Mennell JB. The science and Art of Joint Manipulation. London: Churchill, 1952. • http://www.sofmmoo.com/english_section/7_coccyx/coccyxmv.pdf