OMT for Common Gynecologic Disorders Rebecca Alsip, DO November 15, 2012

Lecture Objectives Review Sympathetic and Parasympathetic innervations pertinent to the female GU system Review and discuss common structural findings and treatment of somatic dysfunction(s) associated with pelvic disorders such as: Premenstrual Syndrome Endometriosis Dysmenorrhea Recognize and explain MFTrP (Myofascial Trigger Points) for the pelvic floor

Female GU Anatomy Any discomfort in the pelvis and sacrum = discomfort during menstruation

Sympathetic innervation from Lesser Splanchnics Parasympatehtics from pelvic splanchnic except gonads, upper ureters and kidney are from vagus nerve Parasympathetic innervation from Pelvic Splanchnic Nerves

Sympathetic Innervation Visceral Organ Spinal Cord Level Corresponding Ganglion Kidneys T10-T11 Superior Mesenteric Adrenal Medulla T10 Upper Ureters Lower Ureters T12-L1 Inferior Mesenteric Bladder T11-L2 Ovaries Uterus/cervix T10-L2 Erectile tissue of clitorus Fallopian tubes Know ovaries and uterus/cerix

Parasympathetic Innervation Visceral Organ Nerves Kidney/upper ureter CN X (vagus) Ovaries Lower ureter/bladder S2-4 (pelvic splanchnics) Uterus and genitalia Remember anything innervated by the vagus you can help treat through suboccpitial release, and cervical stuff - Ovaries develop embrologically w kidneys so that is why they are with vagus and not with pelvic splanchnics Address the pelvic splachnics through the sacrum

Common Gynecologic Disorders Dysmenorrhea Endometriosis Premenstrual Syndrome Pelvic floor dysfunction

Dysmenorrhea Defined as painful menstruation Consists of recurrent, crampy lower abdominal pain that occurs just before or during menses Due to prostaglandin release during endometrial sloughing that causes nonrhythmic uterine contractions No specific physical findings related to the dysmenorrhea itself, but may find pelvic/sacral somatic dysfunctions Treatment includes NSAIDs, OCPs, acupuncture and OMT Chapman’s points along IT band, pubic bone, or sacrum, addressing sympathetics as well as parasympathetics Pelvic Diaphragm to relieve edema and increase drainage OCPs for regulation

Endometriosis Defined as the presence of implanted endometrial glands and stroma in extrauterine locations Often leads to pelvic pain, dysmenorrhea, dyspareunia and infertility Physical exam findings including tenderness and palpable nodules in posterior cul-de-sac and/or uterosacral ligaments, tender adnexal masses and pain with uterine movement Confirmatory diagnosis made by direct observation of endometrial implants Treatment includes pain control, hormone treatments, surgical intervention, as well as OMT Sacral rocking for normalizing parasympathetic tone Treatment of any dysfunction at T10-L2 (uterus) Mobility of pelvic diaphragm to relieve pelvic congestion Uterus doesn’t move well Must do surgery for definite diagnosis, so usually a presumptive diagnosis

Premenstrual Syndrome Presence of both physical and behavioral symptoms that occur repetitively with the menstrual cycle and interfere with a woman’s daily functioning Physical symptoms include abdominal bloating, fatigue, headaches, and breast tenderness Behavioral symptoms include labile mood, irritability, difficulty concentrating and depressed mood Treatment is focused at specific symptoms Headache Tx includes NSAIDs, OCPs or OMT aimed at suboccipital and cervical regions Abdominal bloating Tx includes collateral ganglion release, mesenteric releases of small intestine, ascending and descending colon and colonic milking, as well as associated thoracic and lumbar dysfunctions PMDD is a diagnosis identified by DSM IV

Pelvic Floor Dysfunction Consist of urinary or fecal incontinence, as well as pelvic organ prolapse Can be due to childbirth, pregnancy, nerve injury, or injury to coccygeus or levator ani muscles These can lead to or stem from somatic dysfunction, including TPs Treat with Kegel exercises, injections and OMT Myofascial release, counterstrain, reciprocal inhibition Weakness or tears in any of the muscles listed can lead to any of these pelvic floor dysfunction issues Know that Very common complaint for urinary incontinence with multiple vag deliv Pelvic organ prolapse pretty common too (now that is scary on so many levels)

Treatment of Pelvic Disorders Osteopathic Manipulation Lymphatic drainage Tx of thoracic/lumbars Tx of innominates Tx of pubic bone Tx of sacrum Chapman’s Points Smooth, firm palpable nodules located in the deep fascia Rotary stimulation for 20-60 seconds Travell’s Myofascial Trigger Points

Lymphatics Helps improve vascular congestion Enhances lymphatic drainage Start with thoracic inlet release, then move to the thoracoabdominal diaphragm release, then to pelvic diaphragm Really helpful wit any kind of dysmenorrhea whether related to endometriosis or not - Free up all areas of lymphatic congestion before you go to the next one

Pelvic innominates Can have anterior or posterior innominates due to hamstrings or quadriceps muscles, as well as other pelvic somatic dysfunction Helpful for patients who have pelvic pain Can treat these with muscle energy Can have anterior and posterior innominates due to tight muscles alone

Pubic Bone Dysfunction Can be due to extreme innominate rotation Can also be due to trauma, such as childbirth, or pelvic floor muscle tightness Can treat with muscle energy Get pubic sheers with this - Gap the joint when treating anterior and posterior innominate

Sacral dysfunction Any kind of dysfunction can lead to altered parasympathetic tone Caused from other somatic dysfunctions, trauma, childbirth or pelvic floor muscle dysfunction Can treat with articulatory or muscle energy If your sacrum is out of whack, then your parasympathetic tone will be out of wacky. Fix it. Much sacral dysfunction after childbirth

Anterior Chapman’s Points Screening – anterior If find a + then need to find posterior for confirmation

Posterior Chapman’s Points Confirmatory Screening – anterior If find a + then need to find posterior for confirmation

Travell’s Myofascial Trigger Points Trigger point (TP): hypersensitive focus within taut band of muscle, may or may not follow an injury Direct stimuli initiates trigger points by causing abnormal, continuous input from the muscle spindle, leading to reflex tension in the associated muscle Somatic dysfunction and TPs are closely related and potentiate each other Ex. Emotional stress may be associated with clenching of the teeth and may produce TPs in the masseter and pterygoid muscles Referral pattern follows the muscle  myotomal pattern (know this) External oblique  can cause trigger point that = diarrhea

EMBRYOLOGY OF MYOTOMAL PAIN Myotome – the dorsal part of each somite in a vertebrate embryo, giving rise to the skeletal musculature Dermatome – the lateral wall of each somite in a vertebrate embryo, giving rise to the connective tissue of the skin, an area of the skin supplied by nerves from a single spinal root. 19 Days 19 Days Pretty sure she doesn’t care about this as she stressed “Dr. Williams wanted me to point out the embryo.” Ugh embryo Mesoderm  somites  dermatomyotome and sclerotome Dorsal Mesoderm: on either side of notocord, thickens and arranges itself into pairs called “somites.” Somites form a cluster of mesenchymal cells: Dermomyotome a. Dermatome follows pattern of the skin b. Myotome comes off of the dorsal part  gives rise to the actual muscles…where trigger points come from Sclerotome Myotomal Pain: “charlie horse” sensation Myotomal distribution associated with the location of muscles that share the same neural innervation.

Embryology of Myotomal Pain Remember that trigger points follow a myotomal pattern NOT dermatomal. Can cause pain, weakness and limited ROM that causes motion issues in the muscles  trigger point Myofascial Trigger Points of LE have predictable pain patterns NOT associated with dermatomes. can cause pain, weakness, & limited Rom which can affect joint function. Trigger points are actually a form of Somatic Dysfunction. “Impaired or altered function of myofascial tissues with effects also in related vascular, lymphatic, and neural elements.”

Myotomal Distribution Patterns of Trigger Points Myotomal referral patterns are associated with cramps, weakness, and myofascial trigger points related to muscles that are innervated from the same nerve root. Know piriformis

Pelvic Floor Muscle Trigger Points TPs in lower abdomen may cause urinary frequency, urgency, sphincter spasm, or bladder discomfort Dysfunction of muscles of the pelvic floor can cause innominate rotations, pubic shears Can also cause somatic dysfunction leading to pelvic pain, dysmenorrhea or urinary problems Treatment Muscle Energy Myofascial release Reciprocal inhibition Injection with local anesthetics Spraying with vapocoolant spray Myofascial trigger points refer in myotomal patterns.

Trigger Point vs. Tender Point Trigger Points Tender Points Characteristic pain pattern No typical pain patter Located in muscle tissue Located in muscle, tendons and ligaments Radiating pain pattern No radiating pain pattern Locally tender Taut band of tissue Taut band not present TP is in a ligament = sclerotomal pattern A myotomal issue will stay in a particular muscle so knowing that the referred pain is reproducible and it doesn’t jump all over the place is important Trigger points mapped all over body in the belly of muscles Exam reveals taut band within the muscle with local tenderness, as well as tenderness radiating to an area of the body specific for that muscle Referred pain is reproducible

The part of each somite in a vertebrate embryo giving rise Sclerotomal Pain: The part of each somite in a vertebrate embryo giving rise to bone or other skeletal tissue Referral pattern follows a ligament, bone or joint that shares innervation from the same nerve root deep, achy, toothache quality EX: Iliolumbar ligament Iliolumbar ligament – connects transverse process of L5 to the back of the iliac crest - People complain of pain at the SI joint Sclerotomal – any bone, joint, or ligament - Have characteristic pain pattern

QUESTIONS?? THANK YOU!

REVIEW: SACRAL DIAGNOSIS

Sacral Base Anterior Name: Sacral Base Anterior, Bilateral Sacral Flexion Lateralization: Does NOT matter. Spring test: Negative Landmarks: Sacral Base: Bilaterally (B/L) Anterior Sacral Sulcus: B/L Deep ILA: B/L Posterior STL: B/L Tight Motion: Sacral Base: B/L + ILA: B/L – Ant + Ant+ Deep Deep Post - Post-

Sacral Base Posterior Name: Sacral Base Posterior, Bilateral Sacral EXTENSION Lateralization: Does NOT matter. Spring test: Positive Landmarks: Sacral Base: Bilaterally (B/L) Posterior Sacral Sulcus: B/L Shallow ILA: B/L Anterior STL: B/L Loose Motion: Sacral Base: B/L – ILA: B/L + Post - Post - Shallow Shallow Ant + Ant +

Vertical Axis Diagnosis: less common Name: Left Sacral Margin Posterior Lateralization: Matters NOT. Always call on Posterior side. For Left Sacral Margin Posterior: Landmarks: data recorded on lateralized side Sacral Base: L Posterior Sacral Sulcus: L Shallow ILA: L Posterior STL: L Tight Motion: Sacral Base: L – R + ILA: L – R+ Shallow P – A+ Deep P - A+ How could we treat this?

Findings for Unilateral Sacral Flexion (Sacral Shear) The sacral base on the side of the significantly inferior ILA will generally be anterior: FLEXED The ILA will be significantly inferior (& posterior!) {Sacrotuberous ligament will be pliable and under less tension than the contralateral side.} Anterior Posterior Markedly Inferior Right unilateral sacral flexion

Motion Testing for Unilateral Sacral Flexion (Sacral Shear) There will be no motion at the inferior ILA - it is locked down The base on the same side is likely to have adequate motion There is generally good motion at any of the other locations but the motion is not likely to “add up” or +/- +/- A - P/I (we can’t use our paper model for this one!) (No Axis.)

Unilateral Sacral Extensions Findings: Rare L Base P L sulcus shallow L ILA ant/markedly superior STL loose Spring: may be + Motion: Sacral Base: L - R +/- ILA: L +/- R +/- P- +/- A/S

Left Neutral Sacral Oblique Axis Somatic Dysfunction Name: L on LOA, RL on LOA, L Forward Torsion Landmarks: if calling findings on L side Sacral Sulcus: L Shallow Sacral Base: L Posterior ILA: L Post./ Inf. STL: L Tight Motion Testing: Spring: - (It springs!) Sphinx: - (improves with extension) L5: NSLRR Sacral Base L - R + ILA: L +/- R +/- note: Seated Flexion test may be + on R with this dysfunction (confirmatory) L5: SLRR P - A + +/- P+/- A Neutral - Right Oblique Axis Findings: Name: R on ROA, RR on ROA, R forward torsion Lateralization: Right Landmarks: Sacral sulcus: L deep Sacral base: L anterior ILA: R Post/Inf. STL: R tight Motion Testing: Spring: - L5: SRRL Sacral Base: L + ILA: R +/- Left Right Midline

Right Neutral Sacral Oblique Axis Somatic Dysfunction P+/- A+ L5: SRRL Name: R on ROA, RR on ROA, R Forward Torsion Landmarks: if recording findings on R side Sacral Sulcus: R Shallow Sacral Base: R Posterior ILA: R Post./ Inf. STL: R Tight Motion Testing: Spring: - Sphinx: - L5: NSRRL Sacral Base L + R - ILA: L +/- R +/- Note: Seated flexion test may be + on L with this dysfunction (confirmatory) Left Right Midline

Left Non-Neutral Sacral Oblique Axis Somatic Dysfunction Name: R on LOA, RR on LOA, L Backward Torsion Landmarks: if recording findings on the L side in this example Sacral Sulcus: L Deep Sacral Base: L Anterior ILA: L Ant./Sup. STL: L Loose Motion Testing: Spring: + (It does not spring!) Sphinx: + (findings worsen with extension) L5: confirmatory FRLSL Sacral Base L - R +/- ILA: L + R +/- note: Seated flexion may be + on R with this dysfunction (confirmatory) L5: RLSL P+/- A+ Left Right Midline

Right Non-Neutral Sacral Oblique Axis Somatic Dysfunction Name: L on ROA, RL on ROA, R Backward Torsion Landmarks: if recording findings on R side in this example Sacral Sulcus: R Deep Sacral Base: R Anterior ILA: R Ant./ Sup. STL: R Loose Motion Testing: Spring: + Sphinx + L5: FRRSR Sacral Base L +/- R - ILA: L +/- R + note: seated flexion may be + on L with this dysfunction(confirmatory) L5: RRSR P+/- A+ Left Right Midline