Osteopathy for Endometriosis and Chronic Pelvic Pain - a Pilot Study

! No accurate epidemiological data on the inci- dence of chronic pelvic pain in women, an ill-de- fined term, have been published to date. In a re- view of the international literature, Latthe et al. [1] state a prevalence of 2 –24 % for chronic, non- cyclical pelvic pain; estimates for the USA and Germany are between 7 and 15 % [2 –4]. In gynaecological practice the question often arises as to whether clinical, imaging or endo- scopic findings adequately explain reported pain symptoms [5]. For example, endometriosis has been found in at least 20 % of women undergoing laparoscopic tubal ligation. In Germany the me-

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Pelvic pain is a common problem in gynaecological practice. It is often unclear whether definite causality exists between re- ported symptoms and objective clinical findings of the female genital tract, and medical or opera- tive treatments do not always achieve long-term resolution of symptoms.

This pilot study investigated 28 pa- tients (age 20 –65, median 36.5 years) from a gy- naecology practice whose only clinical finding was painful pelvic floor muscle tightness. Follow- ing standardised gynaecological and physiothera- pist examination, all patients received osteo- pathic treatment. Pain had been present for a me- dian of 3 years (range 1 month to 20 years). 14 pa- tients had previously confirmed endometriosis. Treatment success was evaluated on consultation with patients in person or in writing.

22 of the 28 participants completed the treatment according to plan. Overall, 17 reported symptom improvement, while 10 of the 14 pa- tients with endometriosis did.

Osteopathy is well received by wom- en with painful pelvic floor muscle tightness and appears to be an effective treatment option. Zusammenfassung ! Einleitung: Unterbauchschmerzen sind ein häufi- ges Problem in der gynäkologischen Praxis. Der Kausalzusammenhang zwischen objektivem Be- fund am inneren Genitale und den geklagten Be- schwerden ist oft nicht eindeutig und nicht im- mer führen medikamentöse oder operative The- rapien zu einer dauerhaften Beschwerdefreiheit. Methodik: Im Rahmen einer Pilotstudie wurden 28 Patientinnen (Alter 20 –65, Median 36,5 Jahre) einer gynäkologischen Praxis untersucht. Als ein- ziger klinisch auffälliger Befund fanden sich schmerzhafte Verspannungen des muskulären Beckenbodens. Nach einer standardisierten gynä- kologischen und physiotherapeutischen Unter- suchung wurden diese Patientinnen osteo- pathisch behandelt. Die Schmerzen bestanden seit 3 Jahren (Median, Bereich 1 Monat bis 20 Jah- re). Bei 14 Patientinnen war in der Vorgeschichte eine Endometriose gesichert worden. Der Be- handlungserfolg wurde durch Befragung evalu- iert. Ergebnisse: 22 von 28 Patientinnen schlossen die Therapie planmäßig ab. 17 Patientinnen gaben an, die Beschwerden hätten sich durch die Be- handlung gebessert. Bei den Patientinnen mit En- dometriose gaben 10 von 14 eine Besserung an. Schlussfolgerung: Osteopathie wird von Frauen mit muskulären Verspannungen des Beckenbo- dens gut angenommen und scheint eine wirk- same Therapie darzustellen. Osteopathy for Endometriosis and Chronic Pelvic Pain – a Pilot Study Osteopathie bei Endometriose und chronischen Unterbauchschmerzen – eine Pilotstudie Authors M. Sillem 1, I. Juhasz-Böss 2, I. Klausmeier 3, S. Mechsner 4, F. Siedentopf 5, E. Solomayer 2 Affiliations 1 Praxisklinik am Rosengarten, Mannheim, Germany 2 Frauenklinik Homburg, Uniklinikum Saarland, Homburg/Saar, Germany 3 DC Physiotherapie, Universitätsmedizin Mannheim, Mannheim, Germany 4 Gynäkologie, Campus Benjamin Franklin, Charité, Berlin, Germany 5 Klinik für Gynäkologie und Geburtshilfe, Martin-Luther-Krankenhaus, Berlin, Germany Key words l" endometriosis l" osteopathy l" chronic pelvic pain Schlüsselwörter l" Endometriose l" Osteopathie l" chronische Unterbauch- schmerzen received 29. 3. 2016 revised 15. 5. 2016 accepted 22. 6. 2016

DOI http://dx.doi.org/ 10.1055/s-0042-111010 Geburtsh Frauenheilk 2016; 76: 960–963 © Georg Thieme Verlag KG Stuttgart · New York · ISSN 0016‑5751 Correspondence Dr. Martin Sillem, Priv.-Doz. Dr. med. Praxisklinik am Rosengarten Augustaanlage 7–11 68165 Mannheim Germany [email protected] 960 Sillem M et al. Osteopathy for Endometriosis … Geburtsh Frauenheilk 2016; 76: 960 –963 Deutsche Version unter: http://dx.doi.org/ 10.1055/s-0042-111010 GebFra Science dian interval from endometriosis diagnosis to onset of symptoms is 10.4 years [6]. This highlights the unsatisfactory situation these patients find themselves in, however this particular study sheds no light on whether available treatments are effective. Women with chronic pelvic pain very often have painful pelvic floor muscle tightness [7] – a rare finding in healthy, symptom- free women [8]. Significant comorbidity with musculoskeletal diseases exists, a fact that is not widely acknowledged [9]. The term “osteopathy” describes a school of diagnosis and treat- ment developed by the American Andrew Taylor Still. Its central focus is on musculo-fascial structures and their influence on so- matic symptoms. Three forms of practice have evolved: parietal osteopathy, visceral osteopathy and craniosacral therapy. Evi- dence exists to different degrees – in descending order – support- ing the efficacy of each of the three subdivisions of osteopathy [10]. Osteopathy describes causality between numerous symptoms and diseases due to the fascial connections between the muscu- loskeletal system and the internal organs. Thus, inflammation of internal organs can cause musculoskeletal symptoms and vice versa (e.g. injuries of the axial skeleton can cause abdominal symptoms). Also, functional limitation at one skeletal level may cause symptoms at a different level. These interconnections are described as “lesion chains” [11]. This pilot study investigates the efficacy of osteopathic diagnosis and treatment for women with chronic pelvic pain and painful pelvic floor muscle tightness not related to the menstrual cycle.

! Patients 28 women presented to our clinic at a certified endometriosis centre with chronic lower abdominal symptoms not clearly re- lated to the menstrual cycle. 14 of these patients had previously confirmed endometriosis. In the control group of 14 patients without known endometriosis, 7 had previous abdominal sur- gery for other reasons (uterine fibroids, appendicectomy, chole- cystectomy, Crohnʼs disease, ileus during infancy); specific, endo- scopic exclusion of endometriosis was however not carried out since dysmenorrhea and infertility did not feature as prominent symptoms in this group ( l " Table 1). Group allocation was on the basis of clinical history. Gynaecological examination Apart from the gynaecological history, particular note was taken of symptoms, diseases and injuries of the axial skeleton. All pa- tients underwent a standard gynaecological examination by the same investigator (M. Sillem). Additional transvaginal digital pal- pation of the levator ani and internal obturator muscles was per- formed. Bony landmarks were the inferior pubic ramus and the ischial spine ( l " Fig. 1). A diagnosis of painful muscle tightness was made if there was tenderness on careful palpation. All pa- tients also underwent transvaginal ultrasound examination. All patients were offered further investigation with (repeat) laparos- copy and/or medication as alternatives to osteopathic treatment. Study inclusion Only patients with painful tightness of the pelvic floor muscula- ture were included in the study. Patients with concurrent patho- logical findings on clinical or ultrasound examination of the gen- ital tract (cysts, fibroids) were treated accordingly and excluded from the study. After selection, patients were presented to a physiotherapist with osteopathy training (I. Klausmeier). A clinical history was taken, with particular attention to musculoskeletal and abdomi- nal symptoms/injuries, followed by a systematic examination (sacroiliac joint mobility, tenderness on abdominal palpation, posture, range of motion of the hips, spine). Osteopathic treatment A standardised approach was used starting with release of mus- culoskeletal blocks, particularly of the sacroiliac joints. Depend- ing on clinical findings, this was followed by mobilisation of the diaphragm and abdominal organs using standard techniques. The pelvic floor was released using the so-called “grand manoeuvre” (movement of the abdominal organ compartment in a cranial di- rection). The treatment was concluded in many cases with mobi- lisation of the temporomandibular joints and cervical spine. 1 2 3 4 Fig. 1 Palpation of the pelvic floor muscles. 1: inferior pubic ramus, 2: int. obturator muscle, 3: ischial spine, 4: levator ani muscle. 961 Sillem M et al. Osteopathy for Endometriosis … Geburtsh Frauenheilk 2016; 76: 960 –963 Original Article Each patient was prescribed 6 treatment sessions, of which a me- dian of 6 were carried out (range 1 –24), usually at weekly inter- vals. Evaluation A few weeks after treatment completion, patients were ques- tioned in person or in writing on their satisfaction with the treat- ment.

! Clinical history Duration of symptoms ranged from a few weeks up to 20 years, median 3 years. 21 patients had previously had an abdominal op- eration: 9 had one previous laparoscopy or laparotomy, 8 pa- tients had 2, one patient 3, and 3 patients 4 previous laparosco- pies and/or laparotomies. 10 of the patients with endometriosis were taking or had previ- ously taken hormonal treatment, in 6 cases dienogest mono. Four of these patients had had no improvement of symptoms. 11 patients reported injuries or diseases of the axial skeleton/ musculoskeletal system or specifically the lower limbs (3 motor vehicle accidents, 3 sacral injuries, 2 knee injuries, and 1 each for scoliosis, pelvic ring fracture and multiple fractures). Six pa- tients had had psychotherapy, which had been recommended for a further two patients. Osteopathic treatment Patients underwent a median of 6 (range 1 –24) osteopathic treatment sessions each lasting 30 minutes. 22 patients com- pleted treatment as planned with only two patients discontinu- ing after a single session. The median of repeat prescriptions was 2.5 (range 0 to 5). The group of 14 patients with endometrio- sis differed significantly from the rest of the participants as fol- lows: longer duration of symptoms, more previous operations and both better treatment compliance and outcome ( l " Tables 2 to 4). In contrast there was no difference in comorbidity between the groups. Five out of 11 cases with musculoskeletal diseases/in- juries benefitted from osteopathic treatment, whereas all 5 pa- tients with endometriosis and psychiatric comorbidity did. Three patients without any symptom improvement after osteo- pathic treatment re-presented to the gynaecology clinic: One, with a history of previous endometriosis, required surgery for a newly diagnosed ovarian endometrioma; two were receiving and had benefitted from psychotherapy.

! This feasibility study presents our experience with osteopathy for the treatment of endometriosis and pelvic pain on the basis of muscular tightness. There is little scientific data on the use of osteopathy in general, and available data often has limited validity. In a PubMed search only one study on the described techniques for the treatment of endometriosis was found. Daraï and colleagues [12] used os- teopathy to treat 20 patients with deep infiltrating endometrio- sis, of whom one third had already been operated and 70 % were receiving medication. Physical wellbeing improved in 80 % of pa- tients and 60 % had improved psychological wellbeing. In a Co- chrane Review, however, Proctor et al. [13] concluded that spinal Table 1 Summary of differences between patients with and without endometriosis. Number Duration of symptoms in years median (range) Number of laparoscopies/-tomies median (range) Known endometriosis 14 8 (2 –20) 2 (1 –4) No known endometriosis 14 0.1 (0.1 –5) 0.5 (0 –3) Table 2 Treatment success as a function of previously diagnosed endometriosis. Number Improved Repeat prescription Did not improve Therapy stopped No follow-up Endometriosis 14 10 5 2 1 2 No known endometriosis 14 7 3 1 5 6 Table 3 Treatment success as a function of known/previous musculoskeletal diseases/injuries. Number Improved Repeat prescription Did not improve Therapy stopped No follow-up Positive history 11 5 2 1 2 5 Negative history 17 12 0 2 0 2 Table 4 Comorbidity. Number Musculoskeletal 1 Psychosomatic Known endometriosis 14 6 5 No known endometriosis 14 5 3 1 Previous history of musculoskeletal disease/injury. 962 Sillem M et al. Osteopathy for Endometriosis … Geburtsh Frauenheilk 2016; 76: 960 –963 GebFra Science manipulation (a parietal osteopathic technique) was of no benefit for dysmenorrhea. Chronic pain arising from areas bordering the internal genital or- gans includes backache/low-back pain and urinary tract pain syndromes. A systematic review of osteopathy for lower back pain found numerous studies of which only two were high-qual- ity: One showed an effect no better than placebo, the other found similar effects for osteopathy, conventional physiotherapy and physical/sporting activity [14]. However, a prospective, double- blind, randomised trial of 455 patients, which was published soon thereafter and included a control arm receiving a sham treatment, showed a highly significant positive effect [15]. A sys- tematic review of osteopathy in women with lower urinary tract symptoms also showed a statistically significant positive effect [16]. Endometriosis is a disease prone to recurrence, with recurrence rates estimated at 20 and 50 % respectively two and five years after primary treatment [17]. However, it has also been found in at least 20 % of women undergoing routine tubal ligation for family planning [18]. This means that other causes of pain and al- ternative treatment approaches must be considered, especially when proven effective treatments fail. Endometriosis patients in our study were burdened by long histories of suffering and multi- ple operations. These women were more likely to benefit from osteopathy and had better compliance than women without known endometriosis. A history of injury or disease of the musculoskeletal system with consequent tension of the pelvic floor musculature was common among our study patients. Psychopathological comorbidity was considerable, as shown by the number of women being recom- mended or already receiving psychotherapy. Osteopathy was well received as a treatment option by partici- pants in our study and proved effective in this heterogenous group with multiple previous treatments. On the one hand, the validity of this pilot study is limited by small population size and the lack of systematic follow-up, on the other hand all pa- tients were examined and treated in a standardised fashion by the same two investigators.

! We consider osteopathy to be a valuable additional treatment

as part of the multimodal approach to the treatment of endometriosis and chronic pelvic pain. Conflict of Interest ! The authors declare that no conflict of interest exists.

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