{"paper_id":"8c9a7d25-eb1e-4d9a-bb42-79ea374d3bb4","body_text":"Introduction\n!\nNo accurate epidemiological data on the inci-\ndence of chronic pelvic pain in women, an ill-de-\nfined term, have been published to date. In a re-\nview of the international literature, Latthe et al.\n[1] state a prevalence of 2 –24 % for chronic, non-\ncyclical pelvic pain; estimates for the USA and\nGermany are between 7 and 15 % [2 –4].\nIn gynaecological practice the question often\narises as to whether clinical, imaging or endo-\nscopic findings adequately explain reported pain\nsymptoms [5]. For example, endometriosis has\nbeen found in at least 20 % of women undergoing\nlaparoscopic tubal ligation. In Germany the me-\nAbstract\n!\nIntroduction: Pelvic pain is a common problem in\ngynaecological practice. It is often unclear\nwhether definite causality exists between re-\nported symptoms and objective clinical findings\nof the female genital tract, and medical or opera-\ntive treatments do not always achieve long-term\nresolution of symptoms.\nMethods: This pilot study investigated 28 pa-\ntients (age 20 –65, median 36.5 years) from a gy-\nnaecology practice whose only clinical finding\nwas painful pelvic floor muscle tightness. Follow-\ning standardised gynaecological and physiothera-\npist examination, all patients received osteo-\npathic treatment. Pain had been present for a me-\ndian of 3 years (range 1 month to 20 years). 14 pa-\ntients had previously confirmed endometriosis.\nTreatment success was evaluated on consultation\nwith patients in person or in writing.\nResults: 22 of the 28 participants completed the\ntreatment according to plan. Overall, 17 reported\nsymptom improvement, while 10 of the 14 pa-\ntients with endometriosis did.\nConclusion: Osteopathy is well received by wom-\nen with painful pelvic floor muscle tightness and\nappears to be an effective treatment option.\nZusammenfassung\n!\nEinleitung: Unterbauchschmerzen sind ein häufi-\nges Problem in der gynäkologischen Praxis. Der\nKausalzusammenhang zwischen objektivem Be-\nfund am inneren Genitale und den geklagten Be-\nschwerden ist oft nicht eindeutig und nicht im-\nmer führen medikamentöse oder operative The-\nrapien zu einer dauerhaften Beschwerdefreiheit.\nMethodik: Im Rahmen einer Pilotstudie wurden\n28 Patientinnen (Alter 20 –65, Median 36,5 Jahre)\neiner gynäkologischen Praxis untersucht. Als ein-\nziger klinisch auffälliger Befund fanden sich\nschmerzhafte Verspannungen des muskulären\nBeckenbodens. Nach einer standardisierten gynä-\nkologischen und physiotherapeutischen Unter-\nsuchung wurden diese Patientinnen osteo-\npathisch behandelt. Die Schmerzen bestanden\nseit 3 Jahren (Median, Bereich 1 Monat bis 20 Jah-\nre). Bei 14 Patientinnen war in der Vorgeschichte\neine Endometriose gesichert worden. Der Be-\nhandlungserfolg wurde durch Befragung evalu-\niert.\nErgebnisse: 22 von 28 Patientinnen schlossen die\nTherapie planmäßig ab. 17 Patientinnen gaben\nan, die Beschwerden hätten sich durch die Be-\nhandlung gebessert. Bei den Patientinnen mit En-\ndometriose gaben 10 von 14 eine Besserung an.\nSchlussfolgerung: Osteopathie wird von Frauen\nmit muskulären Verspannungen des Beckenbo-\ndens gut angenommen und scheint eine wirk-\nsame Therapie darzustellen.\nOsteopathy for Endometriosis and Chronic\nPelvic Pain – a Pilot Study\nOsteopathie bei Endometriose und chronischen Unterbauchschmerzen –\neine Pilotstudie\nAuthors M. Sillem 1, I. Juhasz-Böss 2, I. Klausmeier 3, S. Mechsner 4, F. Siedentopf 5, E. Solomayer 2\nAffiliations 1 Praxisklinik am Rosengarten, Mannheim, Germany\n2 Frauenklinik Homburg, Uniklinikum Saarland, Homburg/Saar, Germany\n3 DC Physiotherapie, Universitätsmedizin Mannheim, Mannheim, Germany\n4 Gynäkologie, Campus Benjamin Franklin, Charité, Berlin, Germany\n5 Klinik für Gynäkologie und Geburtshilfe, Martin-Luther-Krankenhaus, Berlin, Germany\nKey words\nl\" endometriosis\nl\" osteopathy\nl\" chronic pelvic pain\nSchlüsselwörter\nl\" Endometriose\nl\" Osteopathie\nl\" chronische Unterbauch-\nschmerzen\nreceived 29. 3. 2016\nrevised 15. 5. 2016\naccepted 22. 6. 2016\nBibliography\nDOI http://dx.doi.org/\n10.1055/s-0042-111010\nGeburtsh Frauenheilk 2016; 76:\n960–963 © Georg Thieme\nVerlag KG Stuttgart · New York ·\nISSN 0016‑5751\nCorrespondence\nDr. Martin Sillem,\nPriv.-Doz. Dr. med.\nPraxisklinik am Rosengarten\nAugustaanlage 7–11\n68165 Mannheim\nGermany\nmartin.sillem@t-online.de\n960\nSillem M et al. Osteopathy for Endometriosis … Geburtsh Frauenheilk 2016; 76: 960 –963\nDeutsche Version unter:\nhttp://dx.doi.org/\n10.1055/s-0042-111010\nGebFra Science\n\n\ndian interval from endometriosis diagnosis to onset of symptoms\nis 10.4 years [6]. This highlights the unsatisfactory situation these\npatients find themselves in, however this particular study sheds\nno light on whether available treatments are effective.\nWomen with chronic pelvic pain very often have painful pelvic\nfloor muscle tightness [7] – a rare finding in healthy, symptom-\nfree women [8]. Significant comorbidity with musculoskeletal\ndiseases exists, a fact that is not widely acknowledged [9].\nThe term “osteopathy” describes a school of diagnosis and treat-\nment developed by the American Andrew Taylor Still. Its central\nfocus is on musculo-fascial structures and their influence on so-\nmatic symptoms. Three forms of practice have evolved: parietal\nosteopathy, visceral osteopathy and craniosacral therapy. Evi-\ndence exists to different degrees – in descending order – support-\ning the efficacy of each of the three subdivisions of osteopathy\n[10].\nOsteopathy describes causality between numerous symptoms\nand diseases due to the fascial connections between the muscu-\nloskeletal system and the internal organs. Thus, inflammation of\ninternal organs can cause musculoskeletal symptoms and vice\nversa (e.g. injuries of the axial skeleton can cause abdominal\nsymptoms). Also, functional limitation at one skeletal level may\ncause symptoms at a different level. These interconnections are\ndescribed as “lesion chains” [11].\nThis pilot study investigates the efficacy of osteopathic diagnosis\nand treatment for women with chronic pelvic pain and painful\npelvic floor muscle tightness not related to the menstrual cycle.\nMaterials and Methods\n!\nPatients\n28 women presented to our clinic at a certified endometriosis\ncentre with chronic lower abdominal symptoms not clearly re-\nlated to the menstrual cycle. 14 of these patients had previously\nconfirmed endometriosis. In the control group of 14 patients\nwithout known endometriosis, 7 had previous abdominal sur-\ngery for other reasons (uterine fibroids, appendicectomy, chole-\ncystectomy, Crohnʼs disease, ileus during infancy); specific, endo-\nscopic exclusion of endometriosis was however not carried out\nsince dysmenorrhea and infertility did not feature as prominent\nsymptoms in this group ( l\n\" Table 1).\nGroup allocation was on the basis of clinical history.\nGynaecological examination\nApart from the gynaecological history, particular note was taken\nof symptoms, diseases and injuries of the axial skeleton. All pa-\ntients underwent a standard gynaecological examination by the\nsame investigator (M. Sillem). Additional transvaginal digital pal-\npation of the levator ani and internal obturator muscles was per-\nformed. Bony landmarks were the inferior pubic ramus and the\nischial spine ( l\n\" Fig. 1). A diagnosis of painful muscle tightness\nwas made if there was tenderness on careful palpation. All pa-\ntients also underwent transvaginal ultrasound examination. All\npatients were offered further investigation with (repeat) laparos-\ncopy and/or medication as alternatives to osteopathic treatment.\nStudy inclusion\nOnly patients with painful tightness of the pelvic floor muscula-\nture were included in the study. Patients with concurrent patho-\nlogical findings on clinical or ultrasound examination of the gen-\nital tract (cysts, fibroids) were treated accordingly and excluded\nfrom the study.\nAfter selection, patients were presented to a physiotherapist\nwith osteopathy training (I. Klausmeier). A clinical history was\ntaken, with particular attention to musculoskeletal and abdomi-\nnal symptoms/injuries, followed by a systematic examination\n(sacroiliac joint mobility, tenderness on abdominal palpation,\nposture, range of motion of the hips, spine).\nOsteopathic treatment\nA standardised approach was used starting with release of mus-\nculoskeletal blocks, particularly of the sacroiliac joints. Depend-\ning on clinical findings, this was followed by mobilisation of the\ndiaphragm and abdominal organs using standard techniques. The\npelvic floor was released using the so-called “grand manoeuvre”\n(movement of the abdominal organ compartment in a cranial di-\nrection). The treatment was concluded in many cases with mobi-\nlisation of the temporomandibular joints and cervical spine.\n1\n2\n3\n4\nFig. 1 Palpation of the pelvic floor muscles.\n1: inferior pubic ramus,\n2: int. obturator muscle,\n3: ischial spine,\n4: levator ani muscle.\n961\nSillem M et al. Osteopathy for Endometriosis … Geburtsh Frauenheilk 2016; 76: 960 –963\nOriginal Article\n\n\nEach patient was prescribed 6 treatment sessions, of which a me-\ndian of 6 were carried out (range 1 –24), usually at weekly inter-\nvals.\nEvaluation\nA few weeks after treatment completion, patients were ques-\ntioned in person or in writing on their satisfaction with the treat-\nment.\nResults\n!\nClinical history\nDuration of symptoms ranged from a few weeks up to 20 years,\nmedian 3 years. 21 patients had previously had an abdominal op-\neration: 9 had one previous laparoscopy or laparotomy, 8 pa-\ntients had 2, one patient 3, and 3 patients 4 previous laparosco-\npies and/or laparotomies.\n10 of the patients with endometriosis were taking or had previ-\nously taken hormonal treatment, in 6 cases dienogest mono. Four\nof these patients had had no improvement of symptoms.\n11 patients reported injuries or diseases of the axial skeleton/\nmusculoskeletal system or specifically the lower limbs (3 motor\nvehicle accidents, 3 sacral injuries, 2 knee injuries, and 1 each\nfor scoliosis, pelvic ring fracture and multiple fractures). Six pa-\ntients had had psychotherapy, which had been recommended\nfor a further two patients.\nOsteopathic treatment\nPatients underwent a median of 6 (range 1 –24) osteopathic\ntreatment sessions each lasting 30 minutes. 22 patients com-\npleted treatment as planned with only two patients discontinu-\ning after a single session. The median of repeat prescriptions\nwas 2.5 (range 0 to 5). The group of 14 patients with endometrio-\nsis differed significantly from the rest of the participants as fol-\nlows: longer duration of symptoms, more previous operations\nand both better treatment compliance and outcome ( l\n\" Tables 2\nto 4). In contrast there was no difference in comorbidity between\nthe groups. Five out of 11 cases with musculoskeletal diseases/in-\njuries benefitted from osteopathic treatment, whereas all 5 pa-\ntients with endometriosis and psychiatric comorbidity did.\nThree patients without any symptom improvement after osteo-\npathic treatment re-presented to the gynaecology clinic: One,\nwith a history of previous endometriosis, required surgery for a\nnewly diagnosed ovarian endometrioma; two were receiving\nand had benefitted from psychotherapy.\nDiscussion\n!\nThis feasibility study presents our experience with osteopathy for\nthe treatment of endometriosis and pelvic pain on the basis of\nmuscular tightness.\nThere is little scientific data on the use of osteopathy in general,\nand available data often has limited validity. In a PubMed search\nonly one study on the described techniques for the treatment\nof endometriosis was found. Daraï and colleagues [12] used os-\nteopathy to treat 20 patients with deep infiltrating endometrio-\nsis, of whom one third had already been operated and 70 % were\nreceiving medication. Physical wellbeing improved in 80 % of pa-\ntients and 60 % had improved psychological wellbeing. In a Co-\nchrane Review, however, Proctor et al. [13] concluded that spinal\nTable 1 Summary of differences between patients with and without endometriosis.\nNumber Duration of symptoms in years\nmedian (range)\nNumber of laparoscopies/-tomies\nmedian (range)\nKnown endometriosis 14 8 (2 –20) 2 (1 –4)\nNo known endometriosis 14 0.1 (0.1 –5) 0.5 (0 –3)\nTable 2 Treatment success as a function of previously diagnosed endometriosis.\nNumber Improved Repeat prescription Did not improve Therapy stopped No follow-up\nEndometriosis 14 10 5 2 1 2\nNo known endometriosis 14 7 3 1 5 6\nTable 3 Treatment success as a function of known/previous musculoskeletal diseases/injuries.\nNumber Improved Repeat prescription Did not improve Therapy stopped No follow-up\nPositive history 11 5 2 1 2 5\nNegative history 17 12 0 2 0 2\nTable 4 Comorbidity.\nNumber Musculoskeletal 1 Psychosomatic\nKnown endometriosis 14 6 5\nNo known endometriosis 14 5 3\n1 Previous history of musculoskeletal disease/injury.\n962\nSillem M et al. Osteopathy for Endometriosis … Geburtsh Frauenheilk 2016; 76: 960 –963\nGebFra Science\n\n\nmanipulation (a parietal osteopathic technique) was of no benefit\nfor dysmenorrhea.\nChronic pain arising from areas bordering the internal genital or-\ngans includes backache/low-back pain and urinary tract pain\nsyndromes. A systematic review of osteopathy for lower back\npain found numerous studies of which only two were high-qual-\nity: One showed an effect no better than placebo, the other found\nsimilar effects for osteopathy, conventional physiotherapy and\nphysical/sporting activity [14]. However, a prospective, double-\nblind, randomised trial of 455 patients, which was published\nsoon thereafter and included a control arm receiving a sham\ntreatment, showed a highly significant positive effect [15]. A sys-\ntematic review of osteopathy in women with lower urinary tract\nsymptoms also showed a statistically significant positive effect\n[16].\nEndometriosis is a disease prone to recurrence, with recurrence\nrates estimated at 20 and 50 % respectively two and five years\nafter primary treatment [17]. However, it has also been found\nin at least 20 % of women undergoing routine tubal ligation for\nfamily planning [18]. This means that other causes of pain and al-\nternative treatment approaches must be considered, especially\nwhen proven effective treatments fail. Endometriosis patients in\nour study were burdened by long histories of suffering and multi-\nple operations. These women were more likely to benefit from\nosteopathy and had better compliance than women without\nknown endometriosis.\nA history of injury or disease of the musculoskeletal system with\nconsequent tension of the pelvic floor musculature was common\namong our study patients. Psychopathological comorbidity was\nconsiderable, as shown by the number of women being recom-\nmended or already receiving psychotherapy.\nOsteopathy was well received as a treatment option by partici-\npants in our study and proved effective in this heterogenous\ngroup with multiple previous treatments. On the one hand, the\nvalidity of this pilot study is limited by small population size\nand the lack of systematic follow-up, on the other hand all pa-\ntients were examined and treated in a standardised fashion by\nthe same two investigators.\nConclusion\n!\nWe consider osteopathy to be a valuable additional treatment\nmethod as part of the multimodal approach to the treatment of\nendometriosis and chronic pelvic pain.\nConflict of Interest\n!\nThe authors declare that no conflict of interest exists.\nReferences\n1 Latthe P, Latthe M, Say L et al. WHO systematic review of prevalence of\nchronic pelvic pain: a neglected reproductive health morbidity. BMC\nPublic Health 2006; 6: 177\n2 Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia,\npelvic pain, and irritable bowel syndrome in primary care practices.\nObstet Gynecol 1996; 87: 55 –58\n3 Mathias SD, Kuppermann M, Liberman RF et al. Chronic pelvic pain:\nprevalence, health-related quality of life, and economic correlates. Ob-\nstet Gynecol 1996; 87: 321 –327\n4 Beutel ME, Weidner K, Brähler E. [Chronic pelvic pain of women and its\nco-morbidity]. Geburtsh Frauenheilk 2005; 65: 61 –67\n5 AWMF, Hrsg. Chronischer Unterbauchschmerz der Frau. AWMF-Leit-\nlinie Reg. Nr. 016/001. 2009. Online: http://www.awmf.org/leitlinien/\ndetail/ll/016-001.html; last access: 25.07.2016\n6 Hudelist G, Fritzer N, Thomas A et al. Diagnostic delay for endometriosis\nin Austria and Germany: causes and possible consequences. Hum Re-\nprod 2012; 27: 3412 –3416\n7 Montenegro ML, Mateus-Vasconcelos EC, Rosa e Silva JC et al. Impor-\ntance of pelvic muscle tenderness evaluation in women with chronic\npelvic pain. Pain Med 2010; 11: 224 –228\n8 Kavvadias T, Pelikan S, Roth P et al. Pelvic floor muscle tenderness in\nasymptomatic, nulliparous women: topographical distribution and re-\nliability of a visual analogue scale. Int Urogynecol J 2013; 24: 281 –286\n9 Ostensen M, Schei B. Sociodemographic characteristics and gynecolog-\nical disease in 40 –42 year old women reporting musculoskeletal dis-\nease. Scand J Rheumatol 1997; 26: 426 –434\n10 Bundesärztekammer. Wissenschaftliche Bewertung osteopathischer\nVerfahren. Dtsch Arztebl 2009; 106: A-2325/B-1997/C-1941\n11 Langer W, Hebgen E, Hrsg. Lehrbuch Osteopathie. Stuttgart: Haug; 2012\n12 Daraï C, Deboute O, Zacharopoulou C et al. Impact of osteopathic manip-\nulative therapy on quality of life of patients with deep infiltrating en-\ndometriosis with colorectal involvement: results of a pilot study. Eur\nJ Obstet Gynecol Reprod Biol 2015; 188: 70 –73\n13 Proctor ML, Hing W, Johnson TC et al. Spinal manipulation for primary\nand secondary dysmenorrhoea. Cochrane Database Syst Rev 2006; (3):\nCD002119\n14 Orrock PJ, Myers SP. Osteopathic intervention in chronic non-specific\nlow back pain: a systematic review. BMC Musculoskelet Disord 2013;\n14: 129\n15 Licciardone JC, Kearns CM, Minotti DE. Outcomes of osteopathic manual\ntreatment for chronic low back pain according to baseline pain severi-\nty: results from the OSTEOPATHIC Trial. Man Ther 2013; 18: 533 –540\n16 Franke H, Hoesele K. Osteopathic manipulative treatment (OMT) for\nlower urinary tract symptoms (LUTS) in women. J Bodyw Mov Ther\n2013; 17: 11 –18\n17 Guo SW. Recurrence of endometriosis and its control. Hum Reprod Up-\ndate 2009; 15: 441 –461\n18 Moen MH. Endometriosis in women at interval sterilization. Acta Ob-\nstet Gynecol Scand 1987; 66: 451 –454\n963\nSillem M et al. Osteopathy for Endometriosis … Geburtsh Frauenheilk 2016; 76: 960 –963\nOriginal Article","source_license":"public-domain-us","license_restricted":false}