Endometriosis, chronic pelvic pain and the role of osteopathic care

One in 10 women of reproductive age will suffer from endometriosis, the major symptoms of which were discussed in an article published in the Winter 2022 issue of Osteo Life. Osteopaths can provide pain relief to those suffering chronic pelvic pain (CPP) as a result of endometriosis. Whether practising with a direct structural approach or visceral, biodynamic or internal techniques, an osteopath’s palpatory skills, alongside their anatomical and physiological knowledge, can downregulate the sensitised nervous system and reduce the symptomatic picture. This article discusses pelvic anatomy, pain mechanisms and the care osteopaths can offer patients with CPP resulting from endometriosis.

ENDOMETRIOSIS AND CHRONIC PAIN Chronic pain states are characterised by sensitisation, manifesting as regional allodynia and hyperalgesia. Individuals with regional pain syndromes such as endometriosis, migraine, interstitial cystitis and irritable bowel syndrome (IBS) also experience central and peripheral sensitisation (Stratton et al, 2015). A potential reason for this is neuroangiogenesis (the growth of nerves and blood vessels), which alters the balance between autonomic neurons and sensory afferents, causing increased nociceptive input with decreased parasympathetic control, amplifying pain (Asante & Taylor, 2011; Hughes et al, 2013; Gebhart & Bielefeldt, 2016) (see box below).

Endometriosis can develop anywhere within the body but is most common in the pelvis, uterus, ovaries, Fallopian tubes, pouch of Douglas, bowel, bladder, peritoneum and uterosacral ligaments. Three subtypes exist: superficial

REBECCA MALON

Rebecca Malon graduated from RMIT University in 2010. She provides both osteopathic and nutritional care and support in her clinic, Freya Health, where she sees primarily women’s health complaints, including chronic pelvic pain, as well as pre-conception, pregnancy and postpartum healthcare. She holds a BHSc in Nutritional Medicine.

The autonomic nervous system and pain

The autonomic nervous system (ANS) is involved in pain physiology and maintenance. The sympathetic nervous system (SNS) and parasympathetic nervous system (PNS) contain both afferent and efferent fibres. Activation of the SNS induces hyperexcitability and initiation of the fight or flight response, while the PNS promotes rest and digestion (Waxenbaum et al, 2021).

If the ANS’s regulatory inhibitory effect on pain is lost, a positive feedback loop is created, producing hyperexcitability of nociceptive nerve fibres, activating the SNS. Sensory nerves relay pain signals to the central nervous system, an important component of pain processing and chronic visceral pain (Brierley & Linden, 2014; Gebhart & Bielefeldt, 2016). Osteopaths can use their diagnostic skills to assess and treat varying spinal levels with the aim of downregulating the SNS and upregulating the PNS in chronic pain conditions (Waxenbaum et al, 2021).

The abdominal and pelvic viscera are innervated by the abdominopelvic splanchnic nerves. These nerves include the greater, lesser, least and lumbar splanchnic nerves. endometriosis, ovarian endometrioma and deep infiltrating endometriosis. This last subtype is multifocal and impacts various structures of the peritoneal cavity, including the uterosacral ligaments, bladder, ureters and digestive tract (Burney & Giudice, 2012; Borghese et al, 2018).

Women can continue to experience debilitating symptoms from endometriosis even after having excision surgery and appropriate hormonal treatment. This is where osteopathy can help. The primary aims of osteopathy are to support the musculoskeletal structures – specifically the bony pelvis and its joints and ligamentous supports – ensure adequate lymphatic and venous return, and mobilise the myofascial system and

viscera, enabling relaxation of the pelvic floor and diaphragm, while balancing the autonomic nervous system (ANS) (Maddern et al, 2020).

PELVIC ANATOMY Mobility and stability of the pelvis and all its joints are important for everyday wellbeing, to ensure optimal load transfer and both static and dynamic function in a controlled manner. When this is altered, dysfunction often proceeds which can impact pelvic floor and pelvic girdle function and the abdominal canister which consists of the pelvic floor, transverse abdominis, diaphragm, multifidus muscles and varying fascia.

Maintaining the mobility and stability of the sacrum, sacroiliac joints and pubic symphysis is essential. It is important to be aware of the links between the uterus, sacrum and pubic symphysis as they relate to many complex urogenital tract movements (Stone, 2007).

Ligaments of note

Sacrococcygeal ligaments connect the sacrum to the coccyx. The anterior sacrococcygeal ligament is a continuation of the anterior longitudinal ligament while the posterior sacrococcygeal ligament is a continuation of the posterior longitudinal ligament and ligamentum flavum, highlighting the influence of spinal mechanics on the pelvis.

Uterosacral ligament. The uterosacral ligament contains elements of smooth muscle and is a common site for endometriosis deposits and adhesion formation. It has extensive connections with the sacrum, piriformis, ischial spine, coccygeus and sacrospinous ligaments. It also expresses hormone receptors and, as such, is influenced by the menstrual cycle (Foti et al, 2018).

Visceral pelvic fascia The bladder, urethra, vagina and uterus are attached to the pelvic walls via the endopelvic fascia, which invests each pelvic organ. Fascia allows the transmission of forces and displays the concept of biotensegrity. The endopelvic fascia is affected by forces and changes in the body; for example, a cervical flexion motion will drag the connective tissue of the pelvic floor superiorly (Herschorn, 2004; Bordoni et al, 2021).

The pelvic fascia and muscles of the abdominopelvic cavity work in unison with the breath, engaging, relaxing and transmitting forces from all directions. Pelvic floor contractions and the endopelvic fascia allow dissipation of force loads from the trunk and upper limbs to the lower limbs and vice versa, while maintaining erect posture and gait. Foot and lower limb function also impact force distribution throughout the pelvis (Bordoni et al, 2021).

Pelvic Diaphragm LEVATOR ANI COCCYGEUS

ANAL CANAL VAGINA URETHRA UROGENITAL DIAPHRAGM SYMPHYSIS PUBIS

Figure 1: The muscles of the pelvic floor

The pelvic floor The pelvic diaphragm – what we know as the pelvic floor – is a wide, thin, muscular layer that forms the inferior border of the abdominopelvic cavity, extending from the pubis to the coccyx and each wall of the pelvis (Figure 1). Muscles include the levator ani – the puborectalis, pubococcygeus and iliococcygeus muscles – and the coccygeus.

The primary functions of the pelvic floor are to support the abdominopelvic viscera, counteract gravitational and inertial forces, maintain continence and sexual function, and facilitate childbirth. These functions cannot occur effectively and pain free without adequate contraction and relaxation of the pelvic floor. Shortening and lengthening of the pelvic floor is dependent on many PERIFORMIS COCCYX OBTURATOR INTERNUS

Levator Ani ILIOCOCCYGEUS PUBOCOCCYGEUS

factors, from the structural position of the bony pelvis and the mobility of its anchor points, to breathing mechanics and pressure gradient changes with the abdomen and respiratory diaphragm, sympathetic tone, pelvic trauma and posture (Herschorn, 2004; Bordoni et al, 2021; Waxenbaum et al, 2021).

Studies have shown that women with endometriosis and chronic pelvic pain (CPP) experience pelvic floor spasm and often have resultant widespread myofascial dysfunction. Research also shows low pressure–pain thresholds and trigger points in various body regions, along with widespread spinal segmental sensitisation throughout the thoracic, lumbosacral and cervical spine (Khachikyan et al, 2010; Phan et al, 2021).

The pelvic floor and respiratory function At rest the pelvic floor resembles the respiratory diaphragm: with contraction it ascends upwards and forwards, on relaxation it moves downwards and backwards. Sacral and coccygeal positioning and mobility are essential in this. With contraction and relaxation, the coccyx moves in a similar manner. Contraction also causes the pelvic viscera to elevate. This rhythmic contraction creates

pressure changes that assist the pelvic viscera in their functions, mobility and motility (Herschorn, 2004; Bordoni et al, 2021).

Many people living with CPP have ineffective breathing patterns and spend much time in a protective fetal position, especially during acute pain flares. They often suck in their stomach while holding their breath, creating unnecessary downward pressure on the pelvic floor, affecting the lymphatics, venous return and ANS. Osteopathically it is imperative to restore diaphragmatic motion, breathing mechanics and thoracic and rib mobility, and to facilitate pelvic floor relaxation (Wurn et al, 2012; Daraï et al, 2015; Goyal et al, 2017).

Pelvic nerves The lumbosacral (Figure 2) and coccygeal plexuses are extremely important in terms of innervating pelvic structures. The nerve supply to the pelvis, particularly the pudendal nerve, can be compromised as a result of poor biomechanics, myofascial dysfunction and entrapment at various locations throughout its pathway through the pelvis.

Other muscles Other muscles to consider when treating endometriosis and CPP are the iliopsoas, piriformis, obturator internus, arcus tendinous of the levator ani, rectus abdominis, transverse abdominis, quadratus lumborum, gluteus medius and tensor fascia latae. It is also important to take account of any surgical scars as well as hip mobility, thoracic mobility, foot biomechanics and cervical spine and jaw function.

ADHESIONS AND PAIN DEVELOPMENT Adhesions within the abdominopelvic cavity reduce the mobility and motility of the peritoneum and visceral structures. They can give rise to pain, producing strong tensions and torsions within the cavity and often contribute to a variety of musculoskeletal problems. Caroline Stone (2007) suggests maintaining intestinal mobility in the early postoperative period to prevent adhesions developing after surgery for endometriosis.

Studies by Sillem and colleagues (2016) and Goyal and colleagues (2017) showed that osteopathic treatment may be favourable for women experiencing abnormal uterine bleeding and CPP. Treatment works within the patient’s pain response and focuses on functional, balancing and gentle mobilisation techniques. Visceral and cranial techniques were utilised in the aforementioned studies, including release of the pelvic diaphragm, sigmoid colon, gastroesophageal junction, hyoid diaphragm, atlantooccipital joint and abdominal diaphragm. Treatment improves mobility and motility of the abdominopelvic viscera and affects myometrial contractions. AT HOME SELF-CARE Osteopaths can teach a number of easy-to-perform self-care techniques to women with CPP resulting from endometriosis.

a b Pelvic floor relaxation An overactive pelvic floor is more common than an underactive one in endometriosis (Maddern et al, 2020). Pelvic floor hypertonia may also be a result of prior trauma, compensatory patterns, chronic infections, inflammation, surgical scarring, holding patterns, hypermobile hips and lumbar spine, stress, and bowel and bladder dysfunction.

Technique to teach

Lay on back with pillows under the head and knees.

Be completely relaxed and free from distraction.

Begin by relaxing jaw, neck and shoulders and focusing on breathing deeply and rhythmically.

Try to initiate a pelvic floor contraction, feeling the pelvic floor lift upwards and forwards and the anal sphincter tighten.

On inhalation, try to fully relax and release the pelvic floor, feeling it move downwards and backwards.

Diaphragmatic breathing If the biomechanics of the diaphragm are compromised, the pelvic floor cannot relax. The benefits of teaching diaphragmatic breathing include pelvic floor relaxation, activation of the parasympathetic nervous system, reduced anxiety and rib cage mobilisation.

Technique to teach

Lay on a flat surface with pillows under the head and knees.

Place one hand on the chest and the other over the belly.

Take a slow deep breath in through the nose.

Feel the belly rise while the chest should stay relatively still.

Exhale slowly through pursed lips – the hand on the belly will feel the abdominal muscles contract and fall in.

Repeat five to 10 times.

Once accustomed to doing this lying down, try it seated, keeping the neck and shoulders relaxed.

Figure 3: Happy baby pose – if this position is not relaxing or comfortable, use a bolster or pillow under the hips, rest the feet on a wall or drop them onto a couch instead

Happy baby pose Happy baby pose can help to lengthen the pelvic floor muscles, particularly when coupled with proper breathing mechanics.

Technique to teach

Lay on back and bring the knees to the chest.

Reach along each leg to grab hold of the ankle, arch of foot or big toe – whichever is accessible.

Open the feet up toward the sky while continuing to bend the knees up toward armpits (Figure 3).

Breathe into the ribs and belly and try to visualise the pelvic floor opening.

Jaw release Jaw release can be carried out by selfinhibition of the masseter and pterygoid muscles internally and/or externally. The jaw, diaphragm and pelvis are intrinsically connected through the deep frontal line. Stress, tension and pain cause contraction of the masseter muscles, diaphragm and pelvic floor (Chen et al, 2012).

Technique to teach

Locate the masseter muscle by placing hands anterior to the ear where your jaw bone meets your cheek, gently clench your jaw, you will feel muscle pop up under your hand (Figure 4).

Using your finger pads apply gentle pressure onto the masseter, slowly

Figure 4: Jaw release

open your mouth and you can apply a downward drag along the masseter to help release this. Repeat three to five times. Alternatively, to release pterygoid internally run your thumb along your top teeth and until you reach the back of the jaw, this can be very tender, apply a lateral (toward the cheek) pressure.

Psoas muscle stretch The psoas muscle greatly impacts CPP thanks to its anatomical location and action. Psoas plays an important role in the lumbo-pelvic-hip complex due to its attachments superiorly on the lumbar vertebra and onto the lesser trochanter of the femur and its function as a hip and lumbar flexor. The psoas also works in conjunction with the diaphragm, abdominals and pelvic floor to help transfer load and alter intraabdominal pressure.

Technique to teach

Position yourself in a low lunge position with one knee on the floor, holding onto something by your side if necessary for balance and support (Figure 5).

The back foot can be flat on the floor or up on the toes. (This stretch can also be performed by placing the back foot on a couch/bench)

Posteriorly rotate the pelvis or tuck the hip/imagine the pelvis is being drawn up toward the ceiling with a piece of string to create that rotation.

Increase the stretch by lunging forward through while maintaining that tucked pelvis posture.

Figure 5: Psoas muscle stretch

Figure 6: Piriformis muscle stretch – if the full stretch (middle) is uncomfortable, lower the free foot to the floor and rest the heel of the other foot on the opposite thigh (right)

Figure 7: Child’s pose – this posture can be modified by resting the arms alongside the body

To increase the stretch further, raise your arm up towards the ceiling.

Piriformis muscle stretch While the piriformis and obturator muscles do not technically make up the pelvic floor, they are situated within the pelvic cavity and have a direct anatomical relationship with the sacrum, hip and pelvic inlet. This stretch is commonly referred to as a 'figure 4 stretch'.

Technique to teach

Lay on back with the knees bent (see Figure 6). Bend one leg up to rest on top of the other creating a figure 4. Bring your leg towards your shoulder or the shoulder on the opposite side (everyone will feel it slightly differently). Alternatively, keep legs down and resting and use your hand to gently press your top knee away from the body as seen in the alternative photo.

Child pose Child pose allows the pelvic floor muscles to lengthen, and it also helps stretch the muscles around the back and hips.

Technique to teach

Begin on all fours, knees wide apart and feet together.

Bring bottom down to sit back on feet.

Rest forehead on the ground or on a rolled-up towel or bolster pillow.

Reach forward with arms over the head or rest arms alongside the body (Figure 7).

Figure 8: Enhancing thoracic mobility: (a) thread the needle; (b) thoracic rotation on all fours; and (c, d) cat-cow

Thoracic spine mobility Exercises to enhance the mobility of the thoracic spine include thoracic extension over a foam roller, thread the needle (Figure 8a), thoracic rotation on all fours (Figure 8b), cat-cow (Figure 8c, d) or sidelying thoracic rotations.

Squatty potty Defecating with the feet elevated and the knees above the hips alters the anorectal angle, enabling complete relaxation of the bowel and pelvic floor, preventing straining (Modi et al, 2019). Because many women with endometriosis will also have concurrent IBS and dyschezia, this simple measure can bring great benefit.

SUMMARY Osteopaths have many skills that can make them an integral part of the team caring for a woman with endometriosis. In a team environment, an osteopath can drive goal-oriented clinical outcomes to reduce pain, improve quality of life and enhance tissue health. The key to successful treatment is to actively engage with the patient, work within their pain response barriers and allow the tissues to heal.

References

Asante, A., Taylor, R.N. (2011) Endometriosis: the role of neuroangiogenesis. Annual Review of Physiology 73, 163–182 DOI: 10.1146/ANNUREVPHYSIOL-012110-142158 Bordoni, B., Sugumar, K., Leslie, S.W. (2021) Anatomy, Abdomen and Pelvis, Pelvic Floor. StatPearls [Internet]. StatPearls Publishing. Available at: www.ncbi.nlm.nih. gov/books/NBK482200/, last accessed 25 July 2022 Borghese, B., Santuli, P., Marcellin, L., Chapron, C. (2018) [Definition, description, clinicopathological features, pathogenesis and natural history of endometriosis: CNGOF-HAS Endometriosis Guidelines]. Gynecologie Obstétrique Fertilité Sénologie 46(3), 156–167 DOI: 10.1016/J.GOFS.2018.02.017 [in French] Brierley, S.M., Linden, D.R. (2014) Neuroplasticity and dysfunction after gastrointestinal inflammation. Nature Reviews Gastroenterology & Hepatology 11(10), 611–627 DOI: 10.1038/nrgastro.2014.103 Burney, R.O., Giudice, L.C. (2012) Pathogenesis and pathophysiology of endometriosis. Fertility and Sterility 98(3), 511–519 DOI: 10.1016/J. FERTNSTERT.2012.06.029 Chen, H., Slade, G., Lim, P.F., Miller, V., Maixner, W., Diatchenko, L. (2012) Relationship between temporomandibular disorders, widespread palpation tenderness and multiple pain conditions: a casecontrol study. Journal of Pain 13(10), 1016–1027 DOI: 10.1016/j.jpain.2012.07.011 Daraï, C., Deboute, O., Zacharopoulou, C., Laas, E., Canlorbe, G., Belghiti, J., Zilberman, S., Ballester, M., Daraï, E. (2015) Impact of osteopathic manipulative therapy on quality of life of patients with deep infiltrating endometriosis with colorectal involvement: results of a pilot study. European Journal of Obstetrics, Gynecology and Reproductive Biology 188, 70–73 DOI: 10.1016/J.EJOGRB.2015.03.001 Foti, P.V., Farina, R., Palmucci, S., Vizzini, I.A.A., Libertini, N., Coronella, M., Spadola, S., Caltabiano, R., Iraci, M., Basile, A., Milone, P., Cianci, A., Ettore, G.C. (2018) Endometriosis: clinical features, MR imaging findings and pathologic correlation. Insights into Imaging 9(2), 149 DOI: 10.1007/S13244-017-0591-0 Gebhart, G.F., Bielefeldt, K. (2016) Physiology of visceral pain. Comprehensive Physiology 6(4), 1609–1633 DOI: 10.1002/CPHY.C150049 Goyal, K., Goyal, M., Narkeesh, K., Samuel, A.J., Sharma, S., Chatterjee, S., Arumugam, N. (2017) The effectiveness of osteopathic manipulative treatment in an abnormal uterine bleeding related pain and health related quality of life (HR-QoL) – a case report. Journal of Bodywork and Movement Therapies 21(3), 569–573. DOI: 10.1016/J.JBMT.2016.08.010 Herschorn, S. (2004) Female pelvic floor anatomy: the pelvic floor, supporting structures, and pelvic organs. Reviews in Urology 6(Suppl 5), S2–S10 Hughes, P.A., Zola, H., Penttila, I., Blackshaw, A.L., Andrews, J., Krumbiegel, D. (2013) Immune activation in irritable bowel syndrome: can neuroimmune interactions explain symptoms? American Journal of Gastroenterology 108(7), 1066–1074 DOI: 10.1038/ ajg.2013.120 Khachikyan, I., Sinaii, N., Shah, J., Ortiz, R., Segars, J., Stratton, P. (2010) CNS sensitization and myofascial dysfunction in patients with endometriosis and chronic pelvic pain. Fertility and Sterility 94(4_Suppl), S40 DOI: 10.1016/J.FERTNSTERT.2010.07.153 Loewy, A. (2020) The Autonomic Nervous System. Britannica. Available at: www.britannica.com/science/ human-nervous-system/The-autonomic-nervoussystem, last accessed 25 July 2022 Maddern, J., Grundy, L., Castro, J., Brierley, S.M. (2020) Pain in endometriosis. Frontiers in Cellular Neuroscience 14, 590823 DOI: 10.3389/ FNCEL.2020.590823 Modi, R.M., Hinton, A., Pinkhas, D., Groce, R., Meyer, M.M., Balasubramanian, G., Levine, E., Stanich, P. (2019) Implementation of a defecation posture modification device: impact on bowel movement patterns in healthy subjects. Journal of Clinical Gastroenterology 53(3), 216–219 DOI: 10.1097/ MCG.0000000000001143 Phan, V.T., Stratton, P., Tandon, H.K., Sinai, N., Aredo, J.V., Karp, B.I. Merideth, M.A., Shah, J.P (2021) Widespread myofascial dysfunction and sensitisation in women with endometriosis-associated chronic pelvic pain: a cross-sectional study. European Journal of Pain 25(4), 831–840 DOI: 10.1002/EJP.1713 Pictures, P. (2015) Anatomy TV. Primal Pictures Ltd. Available at: www-anatomy-tv.ezproxy.endeavour.edu. au/search Sillem, M., Juhasz-Böss, I., Klausmeier, I., Mechsner, S., Siedentopf, F., Solomayer, E. (2016) Osteopathy for endometriosis and chronic pelvic pain – a pilot study. Geburtshilfe und Frauenheilkunde 76(9), 960–963 DOI: 10.1055/s-0042-111010 Stone, C. (2007) Visceral and Obstetric Osteopathy, 1st edn. Churchill Livingstone Stratton, P., Khachikyan, I., Sinaii, N., Ortiz, R., Shah, J. (2015) Association of chronic pelvic pain and endometriosis with signs of sensitization and myofascial pain. Obstetrics & Gynecology 125(3), 719–728 DOI: 10.1097/AOG.0000000000000663 Waxenbaum, J.A., Reddy, V., Varacallo, M. (2021) Anatomy, Autonomic Nervous System. StatPearls [Internet]. StatPearls Publishing. Available at: www.ncbi.nlm.nih.gov/books/NBK539845/, last accessed 25 July 2022 Wurn, B.F., Wurn, L.J., Patterson, K., King, C.R., Scharf, E.S. (2012) Decreasing dyspareunia and dysmenorrhea in women with endometriosis via a manual physical therapy: results from two independent studies. Journal of Endometriosis and Pelvic Pain Disorders 3(4), 188–196 DOI: 10.5301/ JE.2012.9088