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

2. 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

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

4. 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

5. 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

6. 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

7. Common Gynecologic Disorders
Dysmenorrhea
Endometriosis
Premenstrual Syndrome
Pelvic floor dysfunction

8. 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

9. 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

10. 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

11. 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)

12. 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 seconds
Travell’s Myofascial Trigger Points

13. 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

14. 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

15. 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

16. 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

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

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

19. 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

20. 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.

21. 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.”

22. 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

23. 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.

24. 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

25. 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

26. QUESTIONS??
THANK YOU!

27. REVIEW: SACRAL DIAGNOSIS

28. 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-

29. 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 +

30. 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?

31. 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

32. 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.)

33. 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

34. 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

35. 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

36. 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

37. 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